FORUM – PSYCHIATRIC PRACTICE AND RESEARCH: THE VALUE OF INCREMENTAL

AND INTEGRATIVE ADVANCES

Psychiatric diagnosis and treatment in the 21st century: paradigm

shifts versus incremental integration
Dan J. Stein1, Steven J. Shoptaw2, Daniel V. Vigo3, Crick Lund4, Pim Cuijpers5, Jason Bantjes6, Norman Sartorius7, Mario Maj8
1
South African Medical Research Council Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town,
Cape Town, South Africa; 2Division of Family Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA; 3Department of Psychiatry,
University of British Columbia, Vancouver, BC, Canada; 4Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychol-
ogy and Neuroscience, King’s College London, London, UK; 5Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije
Universiteit Amsterdam, Amsterdam, The Netherlands; 6Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa;
7
Association for the Improvement of Mental Health Programmes, Geneva, Switzerland; 8Department of Psychiatry, University of Campania “L. Vanvitelli”, Naples, Italy

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress
in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular
focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have
also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about
etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some
observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence
points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some
proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the
future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; dein-
stitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and
global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches
reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also
that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been
crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further
improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric
practice and research, but rather by incremental progress and iterative integration.

Key words: Mental disorder, psychiatric nosology, clinical neuroscience, personalized psychiatry, Research Domain Criteria, Hierarchical Tax­
onomy of Psychopathology, deinstitutionalization, community mental health care, evidence-based psychotherapy, digital phenotyping, digital
therapies, global mental health, task-sharing approaches, paradigm shifts, incremental integration

(World Psychiatry 2022;21:393–414)

Psychiatry has over the course of its his­
tory been characterized by a range of dif­
ferent models of and approaches to mental
disorder, each perhaps bringing forward
some advances in science and in services,
but at the same time also accompanied
by considerable critique from within and
without the field.
The shift away from psychoanalysis in
the latter part of the 20th century was ac­
companied by key scientific and clinical
advances, including the introduction of
a wide range of evidence-based pharma­
cotherapies and psychotherapies for the
treatment of mental disorders. However,
there has also been an extensive critique
of pharmacological and cognitive-behav­
ioral interventions, whether focused on
concerns about their “medical model”
foundations, or emphasizing the need to
build community psychiatry and to scale
up these treatments globally1.
In the 21st century, global mental health
has become an influential novel perspective
on mental disorders and their treatment.
This emergent discipline builds on advanc­
es in cross-cultural psychiatry, psychiatric
epidemiology, implementation science,
and the human rights movement2. Global
mental health has given impetus to a wide
range of mental health research as well as to
clinical strategies such as task-shifting, with
evidence that these are effective in diverse
contexts and may be suitable for roll-out at
scale3. It is noteworthy, however, that global
mental health has in turn been critiqued for
inappropriate and imperial exportation of
Western constructs to the global South4.
Psychiatric nosology has been a parti­
cular focus of both advances in and critique
from the field. The 3rd edition of the Diag­
nostic and Statistical Manual of Mental Dis­
orders (DSM-III) was paramount, providing
an approach that attempted to eschew dif­
ferent models of etiology, focusing instead
on reliable diagnostic constructs5. These
constructs became widely used in epide­
miological studies of mental illness, in psy­
chiatric research on etiology and treatment,
as well as in daily clinical practice through­
out the world. The most recent editions of
the DSM (DSM-5) and of the International
Classification of Diseases (ICD-11) by the
World Health Organization (WHO) have
drawn on and given impetus to a consider­
able body of work in nosological science6,7.
Early on, psychoanalytic psychiatry crit­
icized DSM diagnostic constructs for miss­
ing core psychic phenomena. With increas­
ing concerns that these constructs have
insufficient validity, neuroscientifically in­
formed psychiatry has put forward ap­
proaches to assessing behavioral phenom­
ena that emphasize laboratory models8.
Despite the growing body of nosology sci­
ence instantiated by the DSM-5 and ICD-
11, many have argued for new paradigms
of classification and assessment – e.g., the
Research Domain Criteria (RDoC), the

World Psychiatry 21:3 - October 2022 393

Hierarchical Taxonomy of Psychopathol­
ogy (HiTOP) and other novel statistical ap­
proaches, and digital phenotyping.
Where do things stand currently with
regard to psychiatry’s models of and ap­
proaches to mental disorder? What are
current clinical practices? What novel per­
spectives are being proposed, and what is
the evidence base for them? To what extent
will newly introduced models of clinical
intervention, such as shared decision-mak­
ing or transdiagnostic psychotherapies, and
novel approaches in psychiatric research,
such as the use of “big data” in neurobio­
logical research and treatment outcome
prediction, have transformative impact for
clinical practice in the foreseeable future?
In this paper we discuss proposed shifts
to clinical neuroscience and personalized
pharmacotherapy, innovative statistical ap­
proaches to psychiatric nosology and assess­
ment, deinstitutionalization and ­community
mental health care, the scale-up of evidence-
based psychotherapy, digital phenotyping
and digital therapies, and global mental
health and task-sharing approaches. We
chose these novel perspectives because
they have achieved particular prominence
recently, and because many have argued
that they will significantly impact psychiat­
ric practice and research in the future.
We consider the extent to which pro­
posed transitions from current practices
to these novel perspectives reflect hype or
hope, and whether they represent para­
digm shifts or iterative progress in psychi­
atric research and practice. Although the
contrast between hype and hope is itself
likely oversimplistic, with many newly
proposed models and approaches in psy­
chiatry representing neither of these polar
extremes, our point of departure is that false
promises of paradigm shifts in health care
may entail significant costs, while hope
may justifiably be considered an important
virtue for health professions9. We begin
with a brief consideration of current mod­
els and approaches in psychiatric practice.
CURRENT MODELS AND
APPROACHES IN PSYCHIATRY
Current practice in psychiatry varies in
different parts of the world, but there are
394
some important universalities. The dura­
tion and depth of training in psychiatry
during the undergraduate and postgradu­
ate years also differ across countries, but
typically a general training in medicine and
surgery is followed by specialized training
in psychiatry, with exposure to both inpa­
tient and outpatient settings. Globally, inpa­
tient psychiatry focuses predominantly (but
not exclusively) on severe mental disorders
such as schizophrenia and bipolar disor­
der, while outpatient psychiatry focuses
predominantly (but again not exclusively)
on common mental disorders such as de­
pression, anxiety disorders, and substance
use disorders. In inpatient settings, psy­
chiatrists are often leaders of a multidisci­
plinary team, with the extent and depth of
this multidisciplinarity dependent on local
resources. There are differences in sub-
specialization across the globe, but in many
countries recognized sub-specialties in­
clude child and adolescent psychiatry, geri­
atric psychiatry, and forensic psychiatry10.
A particularly important shift in the 20th
century has been the process of deinstitu­
tionalization, particularly in high-income
countries. Thus, there has been a decrease
of bed numbers in specialized psychiatric
hospitals, but an increase of these num­
bers in general medical hospitals, with
variable strengthening of community ser­
vices. It has been argued that, when it comes
to mental health services, all countries are
“developing”, since there is a relative un­
derfunding of such services in relation to the
burden of disease1.
Currently, the two major classification
systems in psychiatry are the DSM-5 and
the ICD-11. The DSM system is more com­
monly used by researchers, while the ICD
is a legally mandated health data standard.
The operational criteria and diagnostic
guidelines included in the DSM-III, the
ICD-10, and subsequent editions of the
manuals have exerted considerable influ­
ence on modern psychiatry. They not only
increase reliability of diagnosis, but also
have clinical utility, since they provide cli­
nicians with an approach to conceptualiz­
ing disorders and to communicating about
them11,12. They have also played a key role
in research, ranging from studies of the
neurobiology of mental disorders, through
to studies of interventions for particular
conditions, and on to clinical and commu­
nity epidemiological surveys.
However, there has also been consid­
erable critique of the reliance of modern
psychiatry on the DSM and the ICD. The
notion that psychiatric diagnosis is itself
“in crisis” has come both from within the
field and from external critics. Two some­
what contradictory critiques have been
that in daily practice the DSM and ICD
criteria or guidelines are seldom applied
formally by clinicians, and that over-reli­
ance on those criteria or guidelines leads
to a checklist approach to assessment that
ignores relevant symptoms and important
contextual issues falling outside the focus
of the nosologies. Additional key critiques
have been that psychiatric diagnoses lack
scientific validity, and that current nosolo­
gies are biased by influences such as that
of the pharmaceutical industry13,14.
When thinking about etiology, many cli­
nicians and researchers currently default
to a biopsychosocial model acknowledg­
ing that a broad range of risk and protective
factors are involved in the development
and perpetuation of mental disorders. This
model was introduced by G. Engel in an
attempt to move from a reductionistic bio­
medical approach to include also psycho­
logical and social dimensions15. The model
has important strengths insofar as it takes
a systems-based approach that considers
a broad range of variables influencing dis­
ease onset and course, and attends to both
the relevant biomedical disease and the
patient’s experience of illness16.
Nevertheless, the biopsychosocial ap­
proach has received significant critique.
In particular, it has been argued that the
biomedical model critiqued by Engel is a
straw man, and that the biopsychosocial
approach is overly eclectic and vague.
By saying that all mental disorders have
biological, psychological and social con­
tributory factors, we are unable to be spe­
cific about any particular condition, and
to target treatments accordingly17,18. While
there are few data available on how rigor­
ously psychiatrists consider the range of
risk and protective factors in clinical work,
a review of the research literature indicates
ongoing work on multiple “difference-
makers”, distributed across a wide range of
categories19.
World Psychiatry 21:3 - October 2022
 Psychiatrists are trained to provide a
range of both pharmacological and psy­
chological interventions. However, data
from psychiatric practice networks and
from epidemiological surveys indicate
that there has been a growing emphasis on
pharmacotherapy interventions20, albeit
with some exceptions21. Furthermore, the
number of psychiatrists varies consider­
ably from country to country, and from re­
gion to region within any particular coun­
try22. While primary care practitioners are
also trained to deliver mental health treat­
ments, and indeed provide the bulk of pre­
scriptions for mental disorders in some re­
gions, there is considerable evidence of un­
derdiagnosis and undertreatment of such
conditions in primary care settings.
Indeed, despite the development of a
range of evidence-based pharmacothera­
pies and psychotherapies in the last sev­
eral decades, current data point to both a
treatment gap and a research-practice gap
in mental health. The treatment gap refers
to findings that, across the globe, many
individuals with mental disorders do not
have access to mental health care23. The
research-practice gap, also known as the
“science-practice” or “evidence-practice
gap”, refers to differences between treat­
ments delivered in standard care and
those supported by scientific evidence24.
In particular, clinical practitioners have
been criticized for employing an eclec­
tic approach to choosing interventions,
for not sufficiently adhering to evidence-
based clinical guidelines, and for not em­
ploying measurement-based care.
The treatment gap and the research-
practice gap are of deep concern, given
evidence of underdiagnosis and under­
treatment, of misdiagnosis and inappro­
priate treatment, and of inadequate qual­
ity of treatment25,26. There are, however,
some justifiable reasons for a gap between
practice and research, including that the
evidence base is relatively sparse for the
management of treatment-refractory and
comorbid conditions, the relative lack of
pragmatic “real-world” research trials in
psychiatry, and the possibly modest posi­
tive impact of guideline implementation
on patient outcomes27,28. Indeed, several
scholars have emphasized that including
clinical experience and addressing patient
World Psychiatry 21:3 - October 2022
values are key components of appropriate
decision-making27,29.
Considerably more research is needed
to inform our knowledge of current psychi­
atric practice and its outcomes. Data from
psychiatric practice networks have been
useful in providing fine-grained informa­
tion in some settings, but much further
work is warranted along these lines30. Data
from randomized controlled trials indicate
that psychiatric treatments are as effective
as those in other areas of health care, but
further evidence should be acquired using
pragmatic designs in real-world contexts31.
Epidemiological data from across the globe
suggest that individuals with mental dis­
orders who received specialized, multi-sec­
tor care are more likely than other patients
to report being helped “a lot”, but there is
an ongoing need for more accurate esti­
mates of effective treatment coverage glob­
ally32.
In the interim, evidence of the treatment
gap and the research-practice gap in cur­
rent mental health services has given im­
petus to the development of a number of
novel diagnostic and treatment models and
approaches, ranging from clinical neuro­
science through to global mental health.
Some of these models and approaches have
achieved particular prominence in recent
times, with proponents arguing that they
will significantly impact psychiatric practice
and research in the future. At times advo­
cates for these perspectives and proposals
have limited aims, while at other times they
speak of paradigm shifts that will drasti­
cally alter or wholly reshape current clini­
cal practices33-36. We next consider a num­
ber of these perspectives and proposals in
turn.
CLINICAL NEUROSCIENCE
AND PERSONALIZED
PHARMACOTHERAPY
A key shift in 20th century psychiatry, at
least in some parts of the world, was from
psychoanalytic to biological psychiatry.
The serendipitous discovery of a range of
psychiatric medications in the mid-20th
century, and advances in molecular, ge­
netic and neuroimaging methods, pro­
pelled this shift. More recently, terms such
as clinical neuroscience, translational psy­
chiatry, precision psychiatry, and person­
alized psychiatry have emerged, helping
to articulate the conceptual foundations
for a proposed psychiatric perspective aim­
ing to replace or significantly augment cur­
rent practice37-39.
The proposed paradigm of clinical neu­
roscience rests in part on a critique of cur­
rent standard approaches. First, in terms of
diagnosis, it has been argued that the DSM
and ICD constructs are not sufficiently
based on neuroscience40. Thus, for exam­
ple, particular symptoms, which may in­
volve quite specific neurobiological mech­
anisms, may be present across different
diagnoses. Conversely, research findings
demonstrate that there is considerable
overlap of genetic architecture across dif­
ferent DSM and ICD mental disorders41.
If current diagnostic constructs are not
natural kinds, then arguably attempts to
find specific biomarkers and develop tar­
geted treatments for them are doomed to
fail42,43.
The proposed new paradigm views psy­
chiatry as a clinical neuroscience, which
should rest on a firm foundation of neu­
robiological knowledge44. With advances
in neurobiology, we will be better able to
target relevant mechanisms and develop
specific treatments for mental disorders.
Neuroimaging and genomic research of­
fer opportunities for personalizing psy­
chiatric intervention: those with specific
genetic variants may require tailoring of
psychopharmacological intervention,
while particular alterations in neural sig­
natures may be used to choose a thera­
peutic modality or to alter parameters for
neurostimulation.
The RDoC project, developed by the
US National Institute of Mental Health
(NIMH), has provided an influential con­
ceptual framework for this proposed new
paradigm8. Whereas the DSM-III relied on
the Research Diagnostic Criteria (RDC) in
order to operationalize mental disorders,
the RDoC project emphasizes domains of
functioning that are underpinned by spe­
cific neurobiological mechanisms. Dis­
ruptions in these domains may lead to var­
ious symptoms and impairments. Domains
of functioning are found across species, and
their neurobiological substrates are suffi­
395
ciently known to allow translational neu­
roscience, or productive movement from
bench to bedside and back. Each domain
of functioning can be assessed with spe­
cific laboratory paradigms.
The RDoC matrix initially included five
domains of functioning and several “units
of analysis” for assessing these domains
(see Figure 1)45. Each domain in turn com­
prises a number of different “constructs”
(or rows of the matrix): these were includ­
ed on the basis of evidence that they entail
a validated behavioral function, and that
a neural circuit or system implements the
function. Different “units of analysis” (or
columns of the matrix) can be used to as­
sess each construct: the center column re­
fers to brain circuitry, with three columns
to the left focusing on the genes, molecules
and cells that comprise circuits, and three
columns to the right focusing on circuit
outputs (behavior, physiological respons­
es, and verbal reports). A column to list
paradigms is also included.
The RDoC matrix is intended to include
two further critical dimensions for integrat­
Figure 1  The Research Domain Criteria matrix (from Cuthbert45)
396
ing neuroscience and psychopathology,
i.e. developmental trajectories and envi­
ronmental effects45. Thus, from an RDoC
perspective, many mental illnesses can be
viewed as neurodevelopmental disorders,
with maturation of the nervous system in­
teracting with a range of external influenc­
es from the time of conception. Several key
“pillars” of the RDoC framework, including
its translational and dimensional focuses8,
have been emphasized.
Anxiety, for example, can be studied in
laboratory paradigms, and ranges from
normal responses to threat through to path­
ological conditions. Indeed, a clinical neu­
roscience approach has contributed to the
reconceptualization of several anxiety and
related disorders46-48 and to the introduction
of novel therapeutic approaches for these
conditions49. Further, work on stressors has
usefully emphasized that environmental
exposures become biologically embedded,
with early adversity associated to alterations
in both body and brain that occur irrespec­
tive of the DSM diagnostic category50,51.
The NIMH has linked the RDoC to fund­
ing applications, and this framework has
given impetus to a range of clinical neu­
roscience research. Translational research
will certainly advance our empirical knowl­
edge of the neurobiology of behavior and
of psychopathology. The RDoC has also
prompted conceptual work related to the
neurobiology of mental disorders, and the
development of measures and methods.
Indeed, to the extent that constructs in the
RDoC matrix have validity as behavioral
functions, and map onto specific biologi­
cal systems such as brain circuits, the pro­
ject summarizes key advances in the field,
and provides useful guidance for ongoing
research.
At the same time, it is relevant to note
important limitations of the RDoC ap­
proach. First, the RDoC seems less an en­
tirely new paradigm than a re-articulation
of existing ideas in biological psychiatry.
Certainly, the importance of cross-diag­
nostic neurobiological investigations of
domains of functioning has long been em­
phasized52. Second, the neurobiology of
any particular RDoC construct, such as so­
World Psychiatry 21:3 - October 2022
cial communication, may be enormously
complex, so that alternative approaches to
delineating the mechanisms involved in
particular mental disorders may provide
greater traction53. Third, methods used to
measure domains in the RDoC framework
may not be readily available to clinicians.
The further one moves from academic cen­
ters to the practice of psychiatry in primary
care settings around the globe, the less rel­
evant an RDoC framework may be to daily
clinical work.
Personalized and precision psychiatry
are important aspirations of clinical neuro­
science. The notion that psychiatric inter­
ventions need to be rigorously tailored to
each individual patient makes good sense,
given the substantial inter-individual var­
iability in the genome and exposome of
those suffering from psychiatric disorders,
as well as the considerable variation in re­
sponse to current psychiatric interventions.
With advances in genomic methods and
findings, and the possibility that whole ge­
nome sequencing will become a standard
clinical tool, with polygenic risk scores read­
ily available, it is particularly relevant to
consider the application of genomics to op­
timizing pharmacological and other treat­
ments54.
The Clinical Pharmacogenetic Imple­
mentation Consortium (CPIC) has already
provided a range of clinical guidelines for
drugs used in psychiatry. For example, a
CPIC guideline recommends that, given
the association between the HLA-B*15:02
variant and Stevens-Johnson syndrome
as well as toxic epidermal necrolysis after
exposure to carbamazepine and oxcar­
bazepine, these drugs should be avoided
in patients who are HLA-B*15:02 positive
and carbamazepine- or oxcarbazepine-
naïve55. The evidence base that pharma­
cogenomic testing improves outcomes is
gradually beginning to accumulate, and
recent guidelines have started to recom­
mend a number of specific tests56.
From an RDoC perspective, particular
domains of functioning involve specific
neural circuits, which are in turn modu­
lated by a range of molecular pathways.
One notable recent development in these
fields has been a focus on “big data”. Large
collaborations in basic and clinical scienc­
es have been established, which provide
World Psychiatry 21:3 - October 2022
sufficient statistical power to advance the
field in important ways.
Examples of such “big data” collabo­
rations are the Enhancing Neuroimaging
Meta-analysis Consortium (ENIGMA)57,
which includes tens of thousands of scans
from across the world, and the Psychiat­
ric Genetics Consortium (PGC)58, which
includes hundreds of thousands of DNA
samples from across the globe. The work
of ENIGMA and PGC has been at the cut­
ting edge of scientific research in psychia­
try, and has provided crucial insights into
mental disorders. Certain biological path­
ways, such as immune and metabolic sys­
tems, appear to play a role across different
mental disorders, and genomic methods
have contributed to delineating causal
and modifiable mechanisms underlying
these conditions58,59. At the same time, it
must be acknowledged that to date few
findings from this work have been suc­
cessfully translated into daily clinical prac­
tice36,54,60.
In summary, clinical neuroscience pro­
vides an important conceptual framework
that may generate some useful clinical in­
sights, and that may be particularly helpful
in guiding clinical research. This frame­
work has contributed to the reconceptu­
alization of a number of mental disorders,
and has on occasion contributed to the
introduction of new therapies61. As clini­
cal neuroscience generates new evidence,
this may be incorporated in nosological
systems in the future. There are already
good arguments for including advances in
this area in the curriculum of psychiatric
training, and for updating clinicians on
progress in the field62.
At the same time, there are currently few
biomarkers with clinical utility in psychia­
try, and methods such as functional neu­
roimaging and genome sequencing, which
are key for future advances in frameworks
such as the RDoC, are not readily available
to or useful for practicing clinicians63. The
vast majority of clinical neuroscience pub­
lications appear to have little link to clinical
practice. At best, therefore, we can expect
that ongoing advances in clinical neurosci­
ence will contribute to clinical practice via
iterative advances in our conceptualiza­
tion of mental disorders, and via the ongo­
ing introduction of new insights and new
molecules that emerge from laboratory
studies.
Indeed, the claim that any particular lab­
oratory, neuroimaging or genetic finding
will dramatically change clinical practice
should raise a red flag. The neurobiology of
behaviors and psychopathology is com­
plex, reproducibility of findings is an on­
going important issue, and clinical neu­
roscience investigations only occasion­
ally impact clinical practice64. Indeed, we
should be careful not to be over-optimistic
about clinical neuroscience constituting a
paradigm shift. Neurobiological research
has not to date provided a rich pipeline of
accurate biomarkers for mental disorders,
nor speedily found new molecular entities
that are efficacious for these conditions,
and we cannot, for example, expect that
the DSM and ICD will be replaced by the
RDoC anytime soon.
NOVEL STATISTICAL
APPROACHES TO PSYCHIATRIC
NOSOLOGY, ASSESSMENT AND
RESEARCH
Disease taxonomies are particularly com­
plex, and may not be able to follow histori­
cal models of scientific taxonomies, which
have defined all elements of a given set. An
often-used example of the latter taxonomies
is the periodic table of elements. Another
venerable example is Linnaeus’ Systema
Naturae and the resulting nomenclature of
biological species. The periodic table of ele­
ments has the simplicity of small numbers
plus the hard and fast rules of chemistry,
while the Systema Naturae, despite having
to deal with an ever-expanding number of
entities, is arguably based on direct obser­
vation of beings. In contrast, a disease tax­
onomy deals with thousands of unruly enti­
ties (versus 118 elements), which cannot be
directly observed, apprehended or dissected
(as animals or plants can).
Despite these challenges, disease taxon­
omies have sought to provide a shared, evi­
dence-based, clinically meaningful, com­
prehensive classification that is informed
by etiology and therapeutics. The notion
that underneath the observable syndrome
lies a causal entity, that we should investi­
gate and treat, lies at the heart of the prac­
397
tice of medicine65. Such “disease entities”
have specific characteristics that make
them clear and distinct from others (i.e.,
presentation, etiology, response to inter­
vention), are transparent to the clinician,
and are well-grounded in evidence.
Psychiatry has long faced the challeng­
es of producing a causal nosology that is
able to direct treatment66. Pinel developed
the first comprehensive nosology for peo­
ple with severe mental disorders, along
with moral treatment, the first therapeutic
framework of the scientific era67. Soon af­
terward, Kahlbaum, Kraepelin and Bleuler
laid a firm groundwork for clinical psychi­
atry through close observation and sys­
tematic documentation of the natural his­
tory of severe mental illness. Arguably,
Freud further advanced nosology and ther­
apeutics by focusing on a different set of
disorders (usually milder but much more
prev­alent), which he termed neuroses (to
highlight their difference from psychoses),
and by developing the concept and prac­
tice of psychotherapy. These frameworks
gave im­petus to subsequent advances in
our understanding of and interventions for
mental disorders.
Perceptions of insufficiently rapid and
robust advances in treatments have led to
criticism of current nosology68. In particu­
lar, the DSM and ICD have been criticized
for overly focusing on reliability at the ex­
pense of validity. In this view, schizophre­
nia and bipolar disorder may be genuine
disease entities, but our syndromic defini­
tion lacks specificity, and there are likely dif­
ferent causal pathways that lead to clinically
meaningful subtypes of these disorders.
Major depressive disorder, on the other
hand, is likely to be a hodgepodge of mood
syndromes, some non-dysfunctional (i.e.,
non-disorders) or non-specific (i.e., com­
bining depressive with anxiety symptoms),
including only a few true but potentially
diverse disease entities (e.g., melancholia,
psychotic depression). And when it comes
to, say, personality disorders, the disease-
entity concept is even more distant, and the
search for new approaches is seen as par­
ticularly key.
One such novel paradigm is the HiTOP.
This proposes a hierarchical framework
that, based on the observed covariation of
dimensional traits, is able to identify latent
398
super-spectra and spectra (supra-syn­
dromes), syndromes (our current disor­
ders), and lower-level components69-72. In
this conceptual framework, a dimension
consists of a continuous space in which an
element occurs in differences of degree,
but not of kind, between the normal and
the pathological.
The HiTOP relies on factor analysis and
related techniques, which tap into the co­
variation of observable traits to identify an
unobserved, common factor that, once in­
cluded in the model, explains the covaria­
tion73. Costa and McCrae’s studies leading
to the identification of five personality do­
mains were a prime example of this ap­
proach. There is a common underlying
reason that explains a person’s tendency
to worry about many things, think that
the future looks bleak, be bothered by in­
trusive thoughts, and be grouchy74. That
unobserved factor was conceptualized as
“neuroticism”, and fully explains the co­
variation of these traits in any given indi­
vidual. A similar approach to the study of
childhood psychopathology led to the bi­
nary characterization of an “internalizing”
and an “externalizing” dimension to child­
hood disorders75.
The HiTOP paradigm seeks to leverage
these well-established lines of research to
develop a data-driven nosology that is free
from the theory-driven dead weight built
into current approaches. The key con­
ceptual departure relies on the premise
that, since evidence points towards psy­
chopathological dimensions existing on
a continuum, disorders should be simi­
larly conceptualized, and nosology should
move away from a focus on categorical
entities. Instead of insisting on question­
able boundaries, this approach proposes
dimensional thresholds, which are em­
pirically determined and do not involve
any difference “in kind”. By grouping co-
occurring symptoms within the same syn­
drome, and non-co-occurring symptoms
separately, within-disorder heterogeneity
is reduced. And by assigning overlapping
syndromes to the same unobserved spec­
tra, excess comorbidity found when using
current categories is explained.
The resulting dimensional classifica­
tion, the proponents of HiTOP argue, is
consistent with evidence on risk factors,
biomarkers, course of illness, and treat­
ment response69. Figure 2 shows a schema
of the proposed new nosology. An intrigu­
ing element of this approach is what has
been termed “p”, or general psychopathol­
ogy factor (at the top of Figure 2). In addi­
tion to super-spectra and spectra, factor
analysis ultimately points towards the ex­
istence of a single latent trait that would
explain all psychopathology, comparable
to the well-established “g” factor for gen­
eral intelligence76,77.
If dimensional nosologies seek to over­
turn categorical ones, network analysis
arguably aims to overturn both, insofar as
it posits that the notion of an unobserved
underlying construct is unwarranted, be it a
categorical disease entity or a dimensional
latent factor78. The network approach to
psychopathology holds that mental dis­
orders can be conceived as “problems
in living”, and are best understood at the
level of what is observable. Rather than by
latent entities, disordered states are fully
explained by the interaction between signs
and symptoms (the “nodes” of the net­
works). These interactions are themselves
the causal elements (i.e., a symptom causes
another symptom, then another symptom,
and so on), and a disorder is simply an al­
ternative “stable state” of strongly connect­
ed symptom networks (as opposed to the
“normal” steady state of health).
A conceptualization of disorders as “prob­
lems in living” does away with the medical
notion of a disease as an underlying causal
entity. In this view, deficiencies in our un­
derstanding of etiology are not necessarily
due to diagnostic limitations or insufficient­
ly accurate models for the unobserved but,
on the contrary, may be due to our lack of
attention to the surface, i.e. the symptoms
themselves, which go about reinforcing each
other while we are distracted by peeking be­
hind imaginary curtains.
Unlike dimensional approaches, propo­
nents of network analysis disavow any no­
sological hierarchy (super-spectra, spectra,
disorders, symptoms, etc.), and posit that
there is only one level, that of symptoms,
which can all cause and reinforce one an­
other. Of note, network analysis posits that
symptoms (or interacting nodes) can be
activated by disturbances emerging from
the “external field” (i.e., “external” to the
World Psychiatry 21:3 - October 2022
Figure 2  The Hierarchical Taxonomy of Psychopathology (HiTOP) model (from Krueger et al69)
symptom network, not necessarily to the
body or person), such as the loss of a loved
one (which may activate the symptom
depressed mood, setting in motion the
depressive network) or a brain abnormal­
ity (which may activate the symptom hal­
lucination, setting in motion the psychotic
network).
Whether an individual develops a new
strongly connected network of symptoms
in the face of a stressor depends on his/her
“vulnerability”, which is based on the net­
work’s connectivity. Given a dataset with
symptoms and/or signs for disorders, a
network analysis can quantify all relevant
nodes and interactions, including the fre­
quency and co-occurrence of symptoms,
the strength and number of their associa­
tions, and the centrality of each symptom
(i.e., the sum of the interactions with other
nodes). Empirical work using network
analysis potentially provides rigorous ac­
counts of vulnerability to and evolution of
mental disorders.
A number of other novel statistical ap­
proaches have also been put forward as
potentially facilitating paradigm shifts in
psychiatry. Psychiatry has long relied on
linear models to explore associations and
develop theories of risk and resilience for
mental disorders. However, causal infer­
World Psychiatry 21:3 - October 2022
ence methods have now been developed
in statistics, and provide new approaches
to delineating causal relationships79. In
genetics, Mendelian randomization pro­
vides an innovative method for addressing
the causal relationships of different phe­
notypes, and has increasingly been em­
ployed in psychiatric research80. Neural
networks and deep learning have played
a key role in advancing artificial intelli­
gence, and are increasingly being applied
to the investigation of psychiatric disor­
ders, including prediction of treatment
outcomes81-84. While many view such
techniques as allowing iterative advances,
some are persuaded that they allow an en­
tirely novel perspective and so constitute a
paradigm shift in the field85.
Work on the HiTOP and network analy­
sis has been important and useful in a
number of respects. First, unbiased data-
driven approaches have an important role
in strengthening the relevant science, wheth­
er of nosology, or of areas such as genetics.
A focus on fear-related anxiety disorders,
for example, offers interesting avenues for
research, both from a neuroscience and a
therapeutic perspective, and network analy­
sis has contributed insights into the presen­
tation of some disorders48. Second, some
dimensional constructs, in­cluding those of
internalizing and externalizing disorders,
have clinical utility. The “distress” subfac­
tor reflects the notable overlap between
depressive and anxious symptoms, and
the association between symptoms from
two different disorders (e.g., major depres­
sive disorder and generalized anxiety dis­
order) may be stronger than associations
“within” each disorder86. Third, the use of
novel statistical methods to draw causal
inferences has provided important in­
sights into risk for and resilience to mental
disorders59. For instance, network analysis
offers a nuanced foundation for targeted
treatment of the core symptoms of some
mental disorders (e.g., reframing specific
automatic thoughts through cognitive-
behavioral interventions).
At the same time, such approaches have
important limitations. Notably, categorical
and dimensional approaches are inter­
changeable: any dimension can be con­
verted into a category, and any category
can be converted into a dimension87. There
is no reason to conceptualize mental disor­
ders as exclusively dimensional. In physics,
matter itself is sometimes better conceived
in terms of waves (a dimensional concept)
and other times in terms of particles (a
categorical one). Similarly, in psychiatry, a
pluralist approach that allows the employ­
399
ment of a range of different dichotomous
and continuous constructs seems appro­
priate88,89.
Remarkably, the HiTOP employs DSM
terminology at the disorder level. “Num­
ber-driven” psychopathologies and their
resulting nosologies may not necessar­
ily lead to a shift in constructs grounded
in long-standing clinical practice and re­
search. In the same vein, network analy­
sis offers a useful model to understand
the distribution of symptoms, identify
therapeutic targets, and explain the ef­
fectiveness of symptomatic interventions.
However, network analysis does not spec­
ify the particular levels of explanation that
underlie a network structure; so, while it
may be a useful organizing framework,
it is unclear that it will provide novel in­
sights into underlying etiological mecha­
nisms.
Consider a set of patients presenting
with the following symptoms, among oth­
ers: headaches, vomiting and seizures. A
factor analysis may point towards a latent
factor explaining the covariation among
them. Any clinician will know that, un­
less the cause is substance-related, the
first thing to rule out in these patients is
a space-occupying lesion in the brain,
and that this unobserved element is only
an intermediary that can itself be caused
by multiple disease entities, most nota­
bly hemorrhage, infection and cancer.
The fact that a latent factor may explain
the covariation between anxious and de­
pressive symptoms does not exclude that
these symptoms are in fact caused by very
different dysfunctions (upstream of the
latent factor), and that other accompany­
ing symptoms will hold the clue to the ul­
timate cause (just as high blood pressure,
fever or weight loss would hold clues for a
space-occupying lesion syndrome).
Relatedly, consider the focus of the Hi­
TOP on a general psychopathology factor
“p”. This focus can be countered by a re-
ductio ad absurdum argument suggesting
that a latent factor “i” explains the covaria­
tion of any and all human illnesses. Given
some datasets, we may find that the co­
variation of nausea, hemoptysis, jaundice
and myocardial infarction is explained by a
latent dimensional trait. We may choose to
call this “sybaritism”, dimensionally distrib­
400
uted between one extreme (temperance)
and another (debauchery). Readers who
focus on values-based medicine might
well criticize the choice of words here,
while those focused on evidence-based
medicine are unlikely to be persuaded that
an approach that elides disease entities
will advance studies of psychiatry, gastro­
enterology and cardiology29.
In a latent class analysis of depressive
and anxious syndromes, Eaton et al90 pro­
posed an approach called “guided empiri­
cism”, whereby they explicitly imposed a
theory-driven structure on various statisti­
cal models, compared them, and obtained
the best empirical fit. Perhaps using such
explicitly theory-driven constraints is pref­
erable to accepting hidden theoretical con­
structs. For example, rather than assuming
that all the DSM depressive and some anxi­
ety/stress related disorders are explained by
a latent factor called “distress”, itself under a
spectrum called “internalizing disorders”,
a theory-grounded structure can be im­
posed on the models to try to identify what
is driving the overlap. Indeed, it should be
emphasized that purportedly “number-
driven” nosologies all have built-in qualita­
tive components: from the questions in the
scales used to measure traits, to the labels
chosen for the latent factors, these classifi­
cations are theory-laden.
In summary, the solution to nosologic
challenges in psychiatry may not reside in
the building of new nosologies or psycho­
pathologies from scratch91, nor in the ban­
ishment of the “disease entity” concept, but
rather in continuing the humble, laborious,
iterative work of systematic clinical obser­
vation, painstaking research, and creative
thinking, while purposefully comparing
dimensional, categorical and hybrid mod­
els applied to the same datasets. The claim
that a “quantitative” nosology is somehow
“atheoretical” raises a red flag: where the­
ory is seemingly absent, it is often hidden.
Instead, we need thoughtful and explicit
combinations of theories grounded on
clinical practice and confirmatory quan­
titative evidence. Hypothesis formulation
is a qualitative, creative, theory-laden en­
deavour, while quantitative research helps
us discard false theories and refine what
we know (by proving hypotheses wrong or
quantifying associations).
Similarly, etiological and treatment chal­
lenges in psychiatry are unlikely to be ad­
dressed merely by the employment of larger
and larger datasets, using more and more
sophisticated statistical methods. Certainly,
big data consortia and sophisticated statis­
tical analyses have yielded valuable insights
into the nature of psychiatric disorders. How­
ever, it is important to recognize the limi­
tations of any empirical dataset and any
analytic method, as well as the value of a
wide range of complementary research de­
signs and statistical approaches – including
the age-old single-case study, which may
sometimes provide clinical insights that
outweigh those from big data analyses92.
Indeed, the claim that a new statistical,
bioinformatic or computational method
will provide entirely novel insights that en­
able a paradigm shift in psychiatry should
again raise a red flag. Furthermore, where
solutions reside within a black box, there
is ongoing uncertainty about the extent
to which they will be able to provide clini­
cally useful assistance93,94. Thoughtful and
explicit combinations of existing and novel
research designs and statistical methods
should be employed, with the aim of achiev­
ing iterative and integrative progress in our
diagnosis and treatment of psychiatric dis­
orders.
DEINSTITUTIONALIZATION AND
COMMUNITY MENTAL HEALTH
CARE
The last 70 years have seen a seismic
shift in models of mental health care de­
livery around the world. The first half of
the 20th century was dominated by the
growth of psychiatric hospitals, particular­
ly in high-income Western countries. By
1955, there were 558,239 severely mentally
ill people living in psychiatric hospitals
in the US, with a total population of 164
million at the time95. In the years that fol­
lowed, there was a significant reduction in
psychiatric hospital bed numbers in many
high-income countries, as part of a trend
that came to be known as deinstitution­
alization. In the UK, the US, Australia, New
Zealand and countries in Western Europe,
there was an 80-90% reduction in psychi­
atric hospital beds between the mid-1950s
World Psychiatry 21:3 - October 2022
and the 1990s96.
Deinstitutionalization refers to the down­
scaling of large psychiatric institutions and
the transition of patients into community-
based care. This is said to include three
components: the discharge of people re­
siding in psychiatric hospitals to care in the
community, the diversion of new admis­
sions to alternative facilities, and the de­
velopment of new community-based spe­
cialized services for those in need97. More
recently, a focus in community-based care
has also been the development of models
for integrating mental health into primary
care, as well as of shared decision-making
and recovery approaches98. To the extent
that these models propose new ways of ad­
dressing mental illness, as well as extensive
scale-up of community-based services,
many would argue that they constitute a
crucial paradigm shift.
Deinstitutionalization was driven by
three main forces. First, the introduction
of new medications made it increasingly
possible for people with severe and endur­
ing mental disorders such as schizophre­
nia and bipolar disorder to live reasonably
well in community settings. Second, the
mushrooming of psychiatric hospitals had
come with high costs, and deinstitutionali­
zation was seen by many governments as
a cost-saving strategy. Third, the growth of
the human rights movement in the 1950s
and 1960s generated increasing public
concern about practices in psychiatric
institutions, including involuntary care.
Films such as One Flew over the Cuckoo’s
Nest drew public attention to the condi­
tions in those facilities and provided sup­
port to the idea that people living with
mental disorders should have a choice
over the nature and locus of their care.
This trend was reinforced by research
demonstrating that community-based
models of care, including for people with
severe mental disorders, could be de­
livered effectively, in a manner that was
more acceptable to service users, and in
some cases less costly97.
However, in many regions of the world,
these developments have not actually oc­
curred. Particularly in many post-colonial
low-income countries, for example in sub-
Saharan Africa and South Asia, large psy­
chiatric hospitals have been left behind
World Psychiatry 21:3 - October 2022
by departing administrations, and have
remained the main locus of care. In these
countries, there has been little substantial
deinstitutionalization, and very limited
scaling up of community-based and prima­
ry care mental health services22. In low-in­
come countries, there were 0.02 psychiatric
beds per 100,000 population in 2001, and
this increased to 1.9 beds per 100,000 pop­
ulation in 2020.
The success of deinstitutionalization
programmes in transitioning to commu­
nity-based care has been highly varied
around the world. In some countries,
such as Italy, legislation has mandated
the establishment of community-based
services, and consequently these services
have been widely implemented, although
with substantial variation across the coun­
try99. In many other countries, funding did
not follow people who were discharged
from psychiatric hospitals into commu­
nity settings. For example, in many parts
of the US, deinstitutionalization has been
associated with a burgeoning population
of homeless mentally ill and mentally ill
prisoners95.
In Central and Eastern Europe, even
with recent reforms, studies have criticized
the uneven pace of deinstitutionalization,
the lack of investment in community-
based care, and the “reinstitutionalization”
of many people with severe mental illness
or intellectual disability100. In a tragic case
in South Africa, deinstitutionalization of
2,000 people with severe mental illness or
intellectual disability from the Life Esidi­
meni facility into unlicensed and unregu­
lated community organizations led to the
death of over 140 people, sparking a public
outcry and a national enquiry by the Hu­
man Rights Commission101.
Importantly, deinstitutionalization has
been associated with “revolving door” pat­
terns of care, in which people are discharged
from hospital after admission for an acute
episode, but do not have adequate care and
support in the community, and therefore
relapse and need to be readmitted. Indeed,
readmission rates have been an important
indicator for service managers to monitor in
the post-deinstitutionalization era, and the
focus of several intervention studies102.
The WHO has advocated for the devel­
opment of community-based services for
mental disorders for many decades. In the
early 2000s, it produced a set of guidelines
for countries to develop national mental
health policies, plans and services103. This
included the now widely cited “optimal mix
of services” to guide countries on how to
balance hospital- and community-based
care. This model proposed a pyramid
structure, in which specialist psychiatric in­
patient care represents only a small propor­
tion of services at the apex of the pyramid,
and is supported by psychiatric services in
general hospitals, specialist community
outreach, primary care services, and self-
care at the base of the pyramid. Others have
developed similar “balanced care” mod­
els104.
The 21st century has also seen the de­
velopment of models for integrating men­
tal health into primary care, such as collab­
orative care models105. These latter initially
focused on managing people with comor­
bid depression and other chronic diseases.
Subsequently this work has been expanded
to include other mental disorders, through
models in which a mental health specialist
provides support to non-specialist health
care providers, who are the main point of
contact for people needing care. The WHO
has endorsed this approach, particularly
through its flagship mhGAP programme,
which provides clinical guidelines for the
delivery of mental health care through
non-specialist health care platforms in pri­
mary care and general hospital settings106.
The mhGAP Intervention Guide has now
been implemented in over 100 countries.
In parallel, the latter part of the 20th
century and early 21st century have seen
the rapid development of shared decision-
making and recovery approaches to men­
tal health care. Shared decision-making
involves clinicians and people with men­
tal disorders working together to make de­
cisions, particularly about care needs, in a
collaborative, mutually respectful man­
ner98. This approach is consistent with an
emphasis on human rights, as well as on
the importance of patients’ lived experi­
ence, explanatory models and specific
values, and clearly deserves support107,108.
Recovery models have challenged tradi­
tional roles of “patients” to reframe recov­
ery as a way of living a satisfying, hopeful
life that makes a contribution even within
401
the limitations of illness109. The recovery
movement has been highly influential, is
now incorporated into mental health poli­
cies, and has shaped the design of mental
health systems in several countries109.
Yet, despite the strong scientific and
ethical principles supporting community-
based care, collaborative care and moves
towards shared decision-making and re­
covery approaches, there remain major
challenges, and the proposed paradigm
shift remains to a large extent aspirational.
While community care models have been
developed, tested and shown to be effec­
tive in landmark studies, there are few
cases of countries systematically investing
in these models at scale, in a manner that
substantially influences the mental health
of populations. In addition, although there
are apparent advantages to approaches
such as shared decision-making, a wide
range of barriers across individual, or­
ganizational and system levels have been
reported110, and implementation remains
limited in mental health care98.
Indeed, it has been noticed that the agree­
ment about the concept of shared decision-
making among stakeholders is only super­
ficial98. After all, clinicians may not support
this approach if it leads to patients being
more empowered, but less adherent to treat­
ment recommendations. This example rais­
es broader questions about community-
based care models: is the failure to system­
atically scale up these models just due to a
lack of political will and related scarcity of
resources, or are there fundamental con­
cerns with the model? Our view is that
both of these may be true.
There is certainly a lack of political will
and investment. Despite the courageous
campaigning by people with lived expe­
rience for their rights to make decisions
about their care, together with the robust
evidence of improved outcomes associ­
ated with community-based collaborative
care models, governments often remain
indifferent1. In 2020, 70% of total govern­
ment expenditure on mental health in
middle-income countries was allocated
to mental hospitals, compared to 35% in
high-income countries22. These differences
need to be viewed in the context of massive
global inequities in governments’ com­
mitments to mental health more broadly.
402
While high-income countries spend US$
52.7 per capita on mental health, low-in­
come countries spend US$ 0.08 per capi­
ta22.
On the other hand, it may also be the
case that community-based care does not
go far enough in addressing the social de­
terminants of mental health. While many
community-based care models focus on
individuals with a mental disorder and
their immediate family, very few address
the fundamental structural drivers of men­
tal illness in populations, such as inequal­
ity, poverty, food insecurity, violence, and
hazardous living conditions111,112. Suc­
cessful community-based mental health
services arguably require the existence of
viable communities.
The strategy of deinstitutionalization
was founded on the premise that com­
munities can provide a safe, supportive
environment in which people with severe
mental illness can thrive. In countries
marked by high levels of poverty, inequal­
ity, civil conflict and domestic violence,
this is certainly not the case. Advocating
for community-based care requires ad­
dressing the fundamental social injustices
which precipitate and sustain mental ill­
ness in populations.
Furthermore, community-based service
planners may have not gone far enough in
considering demand-side drivers of mental
health care. For example, in many low- and
middle-income countries, traditional and
faith-based healers continue to be major
providers of care for people with severe
men­tal disorders, due to the scarcity of
main­stream mental health professionals,
and shared beliefs about the causes and
treatments of such conditions.
The effectiveness and cost-effectiveness
of collaborative shared care models with
traditional and faith-based healers has
been documented in Ghana and Nigeria
113
. Similarly, the possibility of addressing
demand-side barriers by implementing
a community informant detection tool,
based on local idioms of distress and vi­
gnettes to identify people with various
mental health conditions, has been dem­
onstrated in Nepal114. These innovations
from low- and middle-income countries
provide potential lessons for high-income
countries in developing collaborative care
models that are aligned with the belief sys­
tems of mental health care users and ad­
dress demand-side barriers to care.
In summary, despite the development
of community-based services, collabora­
tive care, shared decision-making and re­
covery models, a paradigm shift towards
the implementation of well-functioning
and effective community mental health
care around the globe has not occurred.
A red flag should be raised when plans for
community-based services are under-re­
sourced (for example, not providing suffi­
cient human resources to do the work), or
are over-optimistic about implementation
(for example, overlooking important bar­
riers to shared decision-making)115.
Nevertheless, community-based mod­
els have many strengths, and should be
incorporated into attempts to iteratively
improve clinical practices and society re­
sponses to mental disorder. Indeed, it has
been argued that the shift to community-
based services has not been a sudden
change, but rather the culmination of a
slow, gradual, evolutionary development,
which has old historical roots and will
hopefully continue over time116. Efforts to
strengthen community-based approaches
around the world are needed to consoli­
date and extend the advances that have
been achieved.
Taken together, the slow transition from
institutional to community-based mental
health care is partly attributable to the fail­
ure of governments in low-, middle- and
high-income countries to adequately in­
vest in such care – to mandate the funding
to follow people with mental disorders into
their communities and provide them with
the support and choices they need to live
productive meaningful lives – and strate­
gies are needed to persuade them to do
so. But, perhaps to an equally important
degree, there are shortcomings in models
of community care, with unrealistic expec­
tations of a dramatic paradigm shift.
CBT AND THE SCALE-
UP OF EVIDENCE-BASED
PSYCHOTHERAPY
Since its development in the 1970s, cog­
ni­tive behavioral therapy (CBT) has been
World Psychiatry 21:3 - October 2022
at the core of an important shift in clini­
cal practice towards the use of evidence-
based psychotherapies. Hundreds of ran­
domized controlled trials have examined
the effects of CBT for a wide range of men­
tal disorders, including depression, anxi­
ety disorders, substance use disorders,
bipolar disorder, psychotic disorders,
somatoform disorders, eating disorders,
personality disorders, and also other con­
ditions, such as anger and aggression,
chronic pain, and fatigue117. CBT has also
been tested across age groups and specific
target groups, such as women with peri­
natal conditions and people with general
medical disorders117.
Several other types of psychotherapy
have also been rigorously investigated, and
even psychotherapies that had not tradi­
tionally been explored using randomized
controlled trials, such as psychoanalyti­
cally oriented therapies and experiential
therapies, have now also been tested us­
ing such methods118-120. Nevertheless, CBT
is by far the best examined type of psycho­
therapy and therefore dominates the tran­
sition of the field towards the use of evi­
dence-based psychotherapies121.
CBT is highly consistent with a neuro­
biological model of mental ­disorders, inso­
far as it focuses on symptom reduction, im­
provement in functioning, and remission
of the disorder. Furthermore, the literature
on the neurobiological bases of behav­
ioral and cognitive interventions has be­
come increasingly sophisticated122,123, and
a more recent literature on process-based
CBT aligns well with the focus of RDoC on
transdiagnostic mechanisms124. CBT can
therefore be readily combined with neu­
robiologically oriented approaches, espe­
cially pharmacotherapy.
However, despite the strength of the ev­
idence and its compatibility with other ev­
idence-based interventions, CBT has not
been integrated into mental health sys­
tems globally. In many countries, it is still
often seen as a reductionist approach that
does not tackle the real underlying prob­
lems. Psychoanalytic approaches remain
dominant, for example, in France and in
Latin America125.
In low- and middle-income countries,
psychotherapies in general are often not
available for people suffering from men­
World Psychiatry 21:3 - October 2022
tal disorders, due to lack of resources and
trained clinicians. Even in high-income
countries such as the US, the uptake of
psychotherapies has declined since the
1990s20, while the use of antidepressant
medication has increased considerably126,
despite the fact that most patients prefer
psychotherapy over pharmacotherapy127.
In most treatment guidelines, CBT is rec­
ommended as a first-line treatment for sev­
eral mental disorders. However, the actual
implementation of such guidelines in rou­
tine care has been consistently shown to be
suboptimal128-130. In addition, when CBT is
employed, it is unclear whether therapists
actually use it as detailed in standardized
treatment protocols, or whether they com­
bine it with other approaches.
The Increasing Access to Psychologi­
cal Therapies (IAPT) program in the UK
represents the most ambitious attempt to
address the barriers faced by evidence-
based psychotherapy, with scaling up of
CBT across an entire country. The main
goal of the program was to massively in­
crease accessibility to evidence-based
psychotherapies for individuals suffering
from common mental disorders, such as
depression and anxiety disorders.
An important argument for massively
scaling up evidence-based therapies was
economic. Depression and anxiety dis­
orders often start during the working age,
and therefore the economic costs associat­
ed with them are large, due to production
losses and costs of welfare benefits. If these
conditions are treated timeously, costs of
treatment are balanced by increased pro­
ductivity and reduced welfare costs131. A
global return on investment analysis con­
firmed this assumption cross-nationally,
indicating that every invested US dollar
would result in a benefit of 2.3 to 3 dollars
when only economic costs are considered,
and 3.3 to 5.7 dollars when the value of
health returns is included132. Hence, the
hope was that IAPT would pay for itself.
The IAPT model has a number of key
features133. First, patients can be referred
by a general practitioner or another health
professional, but can also be self-referred.
People with depression, generalized anxiety
disorder, mixed anxiety/depression, social
anxiety disorder, post-traumatic stress dis­
order (PTSD), panic disorder, ago­raphobia,
obsessive-compulsive disorder, and health
anxiety receive a person-centered assess­
ment that identifies the key problems, and
an agreed-upon course of treatment is de­
fined131.
Second, IAPT works according to a step­
ped-care model. Patients are first treated
with an evidence-based low-intensity inter­
vention, typically a self-help intervention
based on CBT. Only if this is not appropri­
ate or patients do not recover, they receive
a high-intensity psychological treatment.
Low-intensity therapies are delivered by
“psy­chological well-being practitioners”
who are trained to deliver guided self-help
interventions, either digitally, by telephone,
or face to face. High-intensity therapies are
delivered by therapists who are fully trained
in CBT or other evidence-based interven­
tions.
Third, the therapies offered by IAPT are
those recommended by the UK National
Institute for Health and Care Excellence
(NICE). When the NICE recommends dif­
ferent therapies for a mental disorder, pa­
tients are offered a choice of which therapy
they prefer. This means that IAPT does not
only deliver CBT, although a recurring crit­
icism has been that the program is overly
focused on that type of psychotherapy.
Fourth, outcome data are routinely col­
lected in IAPT. Patients are asked to fill in
various validated questionnaires before
each session, so that clinicians can review
the outcomes and use them in treatment
planning.
Between April 1, 2019 and March 31,
2020, 1.69 million patients were referred
to IAPT, of whom 1.17 million started
treatment, with 606 thousand complet­
ing treatment, and 51% of them reporting
recovery. The proportion of those recov­
ered, however, is substantially lower (26%)
when it is calculated based on those who
started treatment (assuming that dropouts
did not recover), and it has been argued
that IAPT outcomes have been reported in
an overly positive way134,135.
An important issue is that the outcomes
vary considerably across IAPT services. In
2015/2016, the lowest recovery rate was
21% and the highest was 63%. There is
some evidence that recovery rates are high­
er with an increasing number of sessions
and more patients stepping up to more in­
403
tensive therapy136. Other variables that are
associated with better outcomes include
shorter waiting times, lower number of
missed appointments, and a greater pro­
portion of patients who go on with treat­
ment after assessment137.
A recent systematic review and meta-
analysis of the IAPT program identified 60
open studies, of which 47 could be used to
pool pre-post outcome data138. Large pre-
post treatment effect sizes were found for
depression (d=0.87, 95% CI: 0.78-0.96) and
anxiety (d=0.88, 95% CI: 0.79-0.97), and a
moderate effect for functional impairment
(d=0.55, 95% CI: 0.48-0.61).
The IAPT program arguably represents
the state-of-the-art for implementation of
evidence-based psychotherapy in rou­
tine clinical care. Indeed, it has served as
a model for the development of similar
programs in other countries138, including
Australia139, Canada140, Norway141, and
Japan142. More broadly, IAPT indicates
recognition of the importance of mental
health and of the allocation of sufficient
resources to treatment of mental disor­
ders, as well as acknowledgement of the
importance of psychotherapies and their
role in addressing mental disorders.
There are other large scale implemen­
tation programs of CBT, especially in digi­
tal ­mental health care. For example, Mood
GYM143, an online CBT program for depres­
sion, had acquired over 850,000 users by
2015. Psychological task-sharing interven­
tions developed by the WHO, especially
Problem Management Plus, have been
tested in several randomized trials and are
now being implemented in low- and mid­
dle-income countries on a broad scale144,145.
However, the IAPT program is still the larg­
est systematic implementation program of
psychotherapies across the world.
Given the ambitiousness of IAPT, with
extensive and rigorous roll-out across
an entire country, it seems reasonable to
raise the key question of whether this pro­
gram has had real-world impacts, includ­
ing a reduction in the disease burden of
mental disorders. A first issue, however, is
that comparison of IAPT with other treat­
ment services would require a commu­
nity intervention trial in which people are
randomized to either IAPT or “regular”
mental health care. Such a trial has not
404
been conducted and probably never will
be. Thus, although it is possible to claim
on the basis of outcome data from routine
care that other services are as effective as
IAPT146, or that IAPT services may not pro­
vide interventions that match the level of
complexity of the problems of patients147,
it is difficult to validate such claims.
A second issue is whether any mental
health treatments, including IAPT, are truly
capable of reducing the disease burden of
mental disorders. A key modeling study
has estimated that current treatments only
reduce about 13% of the disease burden of
mental disorders at a population level148. In
optimal conditions, in which all those with a
mental disorder receive an evidence-based
treatment, this percentage can be increased
to 40%. So, even under optimal conditions
of 100% uptake and 100% evidence-based
treatments, reduction of disease burden is
not expected to be more than 40%. This is
true for IAPT as well as other programs dis­
seminated on a broad scale.
The limited ability of current treatments
to reduce the disease burden of mental
disorders raises the so-called “treatment-
prevalence paradox”149. This refers to the
fact that clinical treatment rates have in­
creased in the past decades, while popula­
tion prevalence rates of mental disorders
have not decreased. Increased availabil­
ity of treatments could shorten episodes,
prevent relapses, and reduce recurrences,
in turn leading to lower point prevalence
estimates of depression, but this has not
transpired. Most meta-analyses indicate
stable prevalence rates or even small in­
creases in prevalence, despite increased
uptake of services150 and the demonstrat­
ed efficacy of psychiatric treatments31.
There are several possible explanations
for this “treatment-prevalence paradox”149.
First, it is possible that prevalence rates of
depression have dropped, but that at the
same time incidence has increased due to
societal changes. Second, it is possible that
prevalence rates have dropped, but that
emotional distress has been more often di­
agnosed as a depressive disorder over the
past decades, thereby masking the drop.
Third, it is possible that prevalence rates
have not dropped, because treatments
may not be as effective as the field would
like151. Indeed, treatment effects may be
overestimated in trials due to publication
bias, selective outcome reporting, use of
inappropriate control groups, or the al­
legiance effect. Moreover, treatments may
not benefit chronic depressive patients, or
treatments may have iatrogenic effects that
block natural recovery and prolong depres­
sive episodes152.
Taken together, the development of evi­
dence-based psychotherapies has been a
remarkable step forward for psychiatry,
and the scale-up of such effective psycho­
therapies in IAPT and other large-scale
implementation programs has contrib­
uted to consolidating this advancement.
That said, the several criticisms of IAPT
suggest that it is by no means a panacea.
Instead, the implementation of evidence-
based psychotherapies is arguably best
conceptualized as representing incremen­
tal progress. The impact of evidence-based
treatments on the disease burden of men­
tal disorders currently appears to be mod­
est; and the time horizons for introduction
of interventions that are notably more suc­
cessful is unclear.
DIGITAL PHENOTYPING AND
DIGITAL THERAPIES
Rapid technological advances and the
expansion of the Internet have spurred
the development and widespread use of
a host of digital devices with the poten­
tial to transform psychiatric research and
practice153. Indeed, the fourth industrial
revolution and the nudge towards telepsy­
chiatry by the COVID-19 pandemic have
already revealed that digital technologies
provide novel opportunities to improve
psychiatric diagnosis, expand the de­
livery of mental health care, and collect
large quantities of data for psychiatric re­
search154,155.
There are many examples of how these
advances have enabled digital solutions
in psychiatry156,157. To name a few, vir­
tual reality can facilitate exposure therapy
for phobias and PTSD158, chatbots can
deliver remote CBT anonymously day-
and-night159, computer analysis of closed
circuit television (CCTV) images can iden­
tify suicide attempts in progress at suicide
hot-spots160, voice and facial recognition
World Psychiatry 21:3 - October 2022
software may enhance psychiatric diag­
nosis161,162, wearable devices may enable
real-time monitoring and evaluation of pa­
tients163, analyses of human-computer in­
teraction may detect manic and depressive
episodes in real-time164, and suicide risk
may be assessed by analysis of social media
posts165.
Furthermore, the widespread use of dig­
ital medical records, the collection of vast
quantities of data from individuals via
smart devices, the ability to link multiple
databases, and the use of machine learn­
ing algorithms have redefined the use of
big data in psychiatry with the promise of
overcoming the failures of conventional
statistical methods and small samples to
capture the underlying heterogeneity of
psychiatric phenotypes81-83. The ability to
access, store and manipulate data, togeth­
er with the use of machine learning algo­
rithms, promises to advance the practice
of individualized medicine in psychiatry
by allowing matching of patients with the
most appropriate therapies81-83.
Smartphone use is now ubiquitous even
in remote and resource-constrained envi­
ronments across the globe166, making these
devices a powerful medium to improve
access to psychiatric care167. Smartphones
are already being used to deliver interven­
tions for common mental disorders168-171,
and more than 10,000 mental health apps
are available in the commercial market­
place172. There is considerable potential to
turn smartphones into cost-effective and
cost-efficient treatment portals by literally
placing mental health interventions in the
hands of the 6,378 billion people who own
these devices (i.e., 87% of the world’s pop­
ulation), many of whom do not currently
have access to mental health care.
As communication devices, smartphones
can be used to facilitate peer support, de­
liver personalized messages, provide ac­
cess to psychoeducational resources, and
facilitate timely referrals to appropriate in-
person clinical care153. The communication
capabilities of smartphones have enabled
the expansion of telepsychiatry via high-
quality low-cost voice and video calls173,
with evidence indicating that the use of
video conferencing is not inferior to in-per­
son psychiatric consultations174.
Because smartphones are equipped with
World Psychiatry 21:3 - October 2022
a range of sensors and the ability to store
and upload data, they can be easily used
to collect real-time active data (i.e., data
which the user deliberately and actively
provides in response to prompts). Active
data collected via smartphones are already
being used in psychiatry for ecological mo­
mentary assessments, cognitive assess­
ments, diagnosis, symptom monitoring,
and relapse prevention175,176. Beyond these
clinical applications, smartphones are also
powerful tools for data collection in psychi­
atric research177,178.
Digital devices, including smartphones
and wearables, can also collect and store
a host of passive data (that is, data gener­
ated as a by-product of using the device
for everyday tasks, without the active par­
ticipation of the user) with near zero mar­
ginal costs. These passive data have been
likened to fingerprints or digital footprints.
They provide objective continuous longi­
tudinal measures of individuals’ moment-
to-moment behavior in their natural en­
vironments and could be used to develop
precise and temporally dynamic markers
of psychiatric illness, a practice known as
digital phenotyping155,179.
If digital phenotyping delivers on its
promises, it will enable continuous inex­
pensive surveillance of mental disorders
in large populations, early identification
of at-risk individuals who can then be
nudged to access psychiatric treatment,
and early identification of treatment failure
to prompt timely individualized treatment
decisions180. These potential applications
are important, given the dearth of accurate
real-time psychiatric surveillance systems
in many parts of the world, individuals’
reluctance to seek treatment at the early
stages of psychiatric illness, and the high
rates of treatment failure which necessitate
timely adjustments to management.
Identifying digital markers for mental
disorders is, however, not without poten­
tial pitfalls, that will need to be mapped
and navigated before digital phenotyping
can realize its full potential. There are still
unanswered questions about the sensitiv­
ity, reliability and validity of smartphone
sensors for health monitoring and diag­
nosis181. Furthermore, there appears to be
a bias in measurement of everyday activi­
ties from smartphone sensors, because of
variations in how people use their devic­
es182. It still remains to be seen if actuarial
models developed from population level
digital footprints are clinically useful at the
level of individual patients, as well as how
digital phenotyping can be meaningfully
integrated into routine clinical practice,
and how patients will respond to and ac­
cept passive monitoring of their day-to-
day activities180,183.
Digital solutions are not without short­
comings, and a digital intervention is not
necessarily better than no intervention
184-186
. Reviews of the quality and efficacy
of mental health apps indicate that there
is often little evidence to support the effec­
tiveness of direct-to-consumer apps184-186.
Even when mental health apps seem to be
useful, data indicate that many of them suf­
fer from high rates of attrition and are not
used long enough or consistently enough
to be effective187.
Concerns about data privacy and secu­
rity are a significant obstacle to expanding
the use of digital technologies in psychiat­
ric practice and research188,189. Psychiatry
is often concerned with deeply personal,
sensitive, and potentially embarrassing in­
formation, that requires secure data storage
and stringent privacy safeguards. The risks
associated with collecting and storing
digital mental health information need
to be clearly articulated in terms that pa­
tients understand, so that they can pro­
vide informed consent. Privacy policies in
digital solutions such as smartphone apps
are unfortunately often written in inac­
cessible language and “legalese”, making
them incomprehensible to many users189,
and there is as yet insufficient regulation
of mental health apps and no minimum
safety standards188.
While digital technology use has in­
creased across the globe, there are ongoing
inequalities in the access to these technolo­
gies within and between countries166. The
rapid digitalization of psychiatry may unin­
tentionally exacerbate health inequalities
if digital mental health solutions cannot be
shared190. Psychiatry will need to grapple
with thorny questions about how to share
digital technologies with those most in need
of access to mental health care, and how to
develop digital solutions for culturally di­
verse resource-constrained environments.
405
High data costs, unstable Internet connec­
tions, and bandwidth limitations can create
logistical constraints on the utilization of
digital mental health solutions in low-in­
come countries191.
The development of digital mental health
solutions has typically been driven by the
information technology industry and com­
mercial interests172. On the other hand, the
demand for mental health apps has been
largely driven by consumers through so­
cial media, personal searches, and word
of mouth, rather than professional recom­
mendations192. Commercialization of health
care and the repositioning of patients as cus­
tomers has certainly created some efficien­
cies in health care delivery193. However, the
profit motive is not always aligned with good
patient care, as illustrated by the recent opi­
oid crisis194.
Ensuring that clinicians are part of the
process of digitalization of psychiatry will
entail training them to understand, use and
develop digital technologies; establishing
ethical guidelines for the use of these tech­
nologies; ensuring independent evaluation
of the effectiveness of digital interventions
by researchers who have no commercial
interest in the products; and protecting
patient safety by ensuring that the claims
made about the benefits of digital solutions
are supported by robust evidence.
Emerging evidence suggests that screen
time may be associated with mental health
problems, although most of the work in
this area focuses on children and adoles­
cents195-197. While research is mostly cross-
sectional, there are a small number of
longitudinal studies showing that screen
time has small to very small effects on sub­
sequent depressive symptoms, and that
these associations depend on device type
and use198,199. If screen time is bad for men­
tal health, would it be wise to promote the
use of digital mental health interventions
that entail more time online or in front of a
screen? This is not an easy question to an­
swer, and the answer is likely not a simple
yes or no.
The challenge is to think about how
digitizing psychiatry can be balanced with
a careful understanding of the potential
for digital devices to harm mental health.
Few interventions in psychiatry are with­
out potential side effects, and it would be
406
naïve to think that digital ones are differ­
ent. As with any psychiatric treatment, the
prescription of digital interventions needs
to be accompanied with consideration of
the contraindications, advice about how
to use the intervention to its maximum
benefit, and warnings about potential side
effects and how to manage them. To en­
able this we require data, which we do not
yet have, about the contraindications and
side effects of digital interventions188.
We already have evidence to show that
digital technologies can be at least as effec­
tive as traditional practices in making a psy­
chiatric diagnosis, identifying appropriate
individualized interventions, and teaching
psychological skills such as mindfulness
and attentional training180,200,201. Yet, most
clinicians would likely agree that psychi­
atric practice is fundamentally relational
and that most mental illnesses have an in­
terpersonal dimension. The increasing use
of technology in psychiatry will change the
relationship between physician and patient
in ways that we probably do not yet under­
stand and cannot anticipate.
How technology is utilized in psychia­
try will be a function of how central we
think relationships are in diagnosis and
treatment, and whether or not we see
digital technologies as primarily a tool to
enhance the therapeutic relationship, or
simply a conduit to deliver content or col­
lect and process information202. Theories
will need to be developed to conceptual­
ize and understand the digital therapeutic
relationship, while we hold in mind the
potential to harness technology to deepen
the relationship between clinicians and
patients. Indeed, evidence suggests that
digital interventions are most effective
when they have at least some person-to-
person interaction179,200.
Digital technologies may change the
way psychiatry is practiced, but to date
much of the research in this area has been
experimental, with proof-of-concept and
clinical trials in highly controlled settings
using very small samples172. The transla­
tional potential of these technologies has
not yet been realized, and we still have
some way to go to bring digital advances
in mental health “from code to clinic”172.
There are relatively few examples of digital
technologies other than teleconferenc­
ing being used routinely in everyday real-
world psychiatric practice, and there is an
urgent need for pragmatic trials and trans­
lational research to understand the bar­
riers to adoption and implementation of
new technologies203. The attitudes of cli­
nicians and patients towards digital solu­
tions in psychiatry and their perceptions
of the effectiveness and safety of these de­
vices are important determinants of how
widely new technologies will be adopted.
Taken together, the science is still too
young to let us know the extent to which
the introduction of digital technologies
will truly constitute a paradigm shift in
psychiatric diagnosis and treatment, and
whether these technologies will deliver
on their promise to reduce the burden of
disease caused by mental disorders. The
available evidence gives cause for opti­
mism and suggests that these technologies
could assist in iteratively progressing the
science and practice of psychiatry. How­
ever, there are many red flags when it
comes to digital psychiatry, including over­
promising  with regards to efficacy and
overlooking the human relationship. In
order for iterative progress to happen, we
will need continuous critical reflection,
with an ongoing emphasis on equitable
access, appropriate regulation, and quality
assurance204.
GLOBAL MENTAL HEALTH AND
TASK-SHARING
The concept of global health emerged
in the aftermath of World War II, when
cross-national organizations were needed
to coordinate health efforts, particularly
against infectious diseases205. The WHO
was established in 1948, and became a key
advocate for global health, exemplifying
the key pillars of this approach, includ­
ing the recognition that health is a public
good requiring support from all sectors
of the governments, that health involves
a continuum ranging from wellness to ill­
ness, and that the determinants of health
are biological, sociocultural and environ­
mental206. Global health saw the protec­
tion of human rights as a central concern
of all action concerning health, and ex­
pected that action to improve health in­
World Psychiatry 21:3 - October 2022
cludes the formulation of working policies
addressing upstream social determinants
of health, and a strengthening of health
services207.
With growing recognition of the burden
of non-communicable diseases, includ­
ing mental, neurological and substance
use disorders, global mental health be­
came an important focus. B. Chisholm, a
psychiatrist who was the first WHO Direc­
tor General, introduced the mantra “No
health without mental health”208. An early
4x4 model of non-communicable diseases
emphasized the comorbidity of cardiovas­
cular diseases, diabetes, cancer and respi­
ratory diseases with tobacco use, unhealthy
diet, physical inactivity and harmful alco­
hol use as risk factors for these conditions.
A later 5x5 approach has emphasized that
these non-communicable diseases are com­
monly comorbid with mental disorders, and
that childhood adversity is an important
common risk factor209.
Over the past several decades, global
mental health has become a significant
discipline, with specific departments es­
tablished at several leading universities,
textbooks and journals devoted to the
subject, and significant support for re­
search obtained from funders210. In addi­
tion to a focus on mental health as a public
good and human right, on mental health
as entailing a continuum and a life course
approach, on the importance of social de­
terminants of mental health, and on the
need of strengthening mental health ser­
vices, work in global mental health has
emphasized the efficacy of task-shifting
interventions, the importance of address­
ing stigma, and the value of including ser­
vice users’ perspectives in research and
planning1,2.
Early work by the WHO, and subsequent
work by others in global mental health, has
led to important contributions. A first key
contribution has been the recognition of
the burden of mental disorders, and advo­
cacy that this burden needs to be urgently
and appropriately addressed. There are far
too few mental health clinicians in low-
and middle-income countries, where the
vast majority of the world’s population re­
sides22.
A second key contribution has been a
focus on addressing mental health in pri­
World Psychiatry 21:3 - October 2022
mary care. In the 1970s, the WHO conduct­
ed a multinational collaborative study
dem­onstrating the feasibility and effective­
ness of offering community-based mental
health care, delivered by primary health
care work­ers, in developing countries211. A
few years later, in 1978, the Primary Health
Care Conference in Alma Ata, composed
of representatives of almost all countries in
the world, included the promotion of men­
tal health into the list of essential compo­
nents of primary health care.
Nevertheless, global health in general
and global mental health in particular
have faced many challenges. Early hopes
were that globalization would entail a
border-free world with easy communica­
tion, trade, and mutual support. However,
globalization has also arguably allowed
unidirectional unloading of products of
the North to the less industrially devel­
oped South, and a simultaneous migra­
tion of many individuals, including health
professionals, from the global South to the
North. Colonial practices, including large
psychiatric hospitals, have remained in
existence in many low-income countries.
Rapid urbanization and breakdown of tra­
ditional communities, which provided some
support to vulnerable individuals, have fur­
ther complicated the provision of health
care. The introduction of digital technolo­
gies – which has been considered as a po­
tential equalizer – also runs the risk of creat­
ing a new divide, the digital divide.
In terms of the clinical practice of psy­
chiatry, while the numbers of psychiatrists
and other mental health care workers has
significantly increased across the globe,
their inequitable distribution has not sig­
nificantly improved22. There are still many
countries with only a few psychiatrists, and
the brain drain – the movement of fully
trained psychiatrists from the global South
to the North – continues212. Training pro­
grams which can be used for primary health
care providers in mental health have been
produced by the WHO and other agencies,
and the situation has improved in some
countries, but the numbers of those left
with no adequate care remain high. Prima­
ry care practitioners are not always willing
to accept responsibility for the treatment of
mental disorders, and many well-trained
psychiatrists have continued to work in pri­
vate health care services that reach only a
minority of those who need help.
Earlier sections of this paper consid­
ered some of the concerns about current
psychiatry nosology raised by neurobio­
logically-focused and “number-driven”
researchers. But even from a public health
perspective, application of key aspects
of the chapter on mental disorders of the
ICD rises problems213. First, most practic­
ing clinicians feel that in daily work the
number of diagnostic categories proposed
for use should follow the number of op­
tions for therapeutic interventions, and
so ICD approaches may be too complex.
Second, reporting about inpatient men­
tal health services to national authorities
in most instances follows the guidelines
provided by hospitals, which do not allow
for the collection of sufficiently detailed or
validated data. The interpretation of find­
ings may be made even more difficult by
the fact that in federal countries the rules
of reporting to the central authority differ
from area to area.
Global mental health has been crucially
important in putting forward a number of
innovative models and approaches. At the
same time, critics might suggest that the
strategies of global mental health are not
so much an entirely new paradigm but in­
stead a re-packaging of long-standing ideas
in the field, and that each of these strategies
has important limitations which deserve
emphasis.
First, global mental health has focused
on the notion of “task-shifting”. This in­
volves the use of non-specialized health
care workers, who are trained and super­
vised by mental health specialists. System­
atic reviews have concluded that there is
now considerable evidence for the efficacy
of this approach3,214. Nevertheless, this
strategy is not a panacea. There are limits
to what can be done by untrained person­
nel. The treatment of more complex condi­
tions, such as treatment-refractory mental
disorders, requires well-trained clinicians.
Moreover, significant supervision and
monitoring may be required, and this en­
tails human and financial resources. There
is now interest in how to assess therapist
competence in task-shifting trials215,216. Fi­
nally, there is a difference between demon­
stration projects conducted by academic
407
researchers and real-life scale-up projects
undertaken by governments. Pharmaco­
therapy outcomes are worse in real-world
pragmatic trials than in academic-centre
explanatory trials, and we might expect
that the same will hold true in the case of
task-shifting research.
A second important strategy of global
mental health has been to build the invest­
ment case for mental health, demonstrat­
ing the return on investment for countries
scaling up community-based care. As
noted earlier, this gave key impetus to the
implementation of psychotherapies in the
UK. However, a number of challenges re­
main. Many economic returns accrue to
sectors outside ministries of health, which
traditionally hold mental health budgets.
Economic returns on scaled-up mental
health care are likely to accrue through
improved labour market participation, re­
duced homelessness, and savings to cor­
rectional services and police services, and
not necessarily to the health sector. More­
over, such savings might only be realized
at some time in the future, creating what
has been termed pernicious “diagonal ac­
counting”217. Finally, it must be conceded
that not all investment in mental health
– for example, care for those with severe
neurodevelopmental disorders – will yield
significant economic returns.
A third key strategy of global mental
health has been to focus on building strong­
er, better coordinated advocacy, with part­
nerships between people with lived experi­
ence and clinicians to campaign for better
and more resources for mental health care.
It has been argued that ongoing dialogue
between the various stakeholders involved
in community-based care is essential to
reach common ground on service devel­
opment priorities. This should also include
maximizing opportunities for leadership
from people with lived experience, to ad­
dress demand-side barriers to community-
based mental health care. Nevertheless,
there are key barriers to advocacy work,
including low mental health literacy of poli­
cy-makers, and a gap in frameworks linking
research to policy218.
A fourth key strategy of global mental
health has been to focus on stigma reduc­
tion strategies. Certainly, reducing stigma
and discrimination against people ­living
408
with mental illness is vital if we are to pro­
mote care in the community. Furthermore,
there is a growing evidence base for the
positive impact of stigma reduction cam­
paigns for mental health, such as the World
Psychiatric Association’s “Open the Doors”
program. At the same time, there are im­
portant challenges to acknowledge. Much
more needs to be done to both improve
the effectiveness of these interventions
and extend stigma reduction programmes
to a range of different countries219. Stigma
reduction strategies should not deny the
dysfunction that accompanies severe
mental disorders (services for such con­
ditions remain sorely needed), and they
need to also highlight that individuals suf­
fering from psychiatric disorders have “re­
sponsibility without blame”220. Finally, it is
notable that, in some contexts, providing
neurobiologically focused information in­
creases rather than decreases stigma221.
A fifth key strategy of global mental
health is to address social determinants
of mental disorders. Governments need
to address fundamental social injustice
such as rampant inequality, high unem­
ployment, civil conflict and violence, par­
ticularly gender-based violence, that drive
mental disorders in populations222. That
said, the evidence base for population-
level interventions to address the social
determinants of mental health is rather
sparse and of low quality223. Ironically,
global mental health has been accused
of ignoring key contextual data224, and of
perpetuating some of the sociopolitical in­
equities it critiques225. Less contentiously,
while some clinicians may well contribute
to efforts focused on social determinants,
the majority will focus on providing direct
clinical care. Public mental health skills
are needed to supplement, rather than re­
place, standard clinical training.
Taken together, it is clear that the con­
cepts and methods of global mental health
have many strengths, have contributed to
important advances, and should be incor­
porated into further attempts to incremen­
tally improve health policies as well as clini­
cal practice. As always, discourse about a
paradigm shift and over-optimism about
the extent of envisaged change raise red
flags. Indeed, the key strategies of global
mental health that may facilitate ongoing
incremental progress may themselves re­
quire iterative attention: we need to contin­
ue to be innovative about task-sharing, to
gradually strengthen the investment case,
to steadily develop better advocacy strate­
gies, to further reduce stigma about mental
disorders and increase mental health lit­
eracy, and to better address social determi­
nants of these conditions.
DISCUSSION
Kuhn’s notion of scientific paradigms
has been extraordinarily influential226. He
argued that most of science is “normal”:
scientists have a particular conceptual
framework, with various exemplars that
are key for the field, which allows them to
address a range of relatively minor “puz­
zles”227. However, from time to time, there
is a paradigm shift, with an entirely new
conceptual framework and new exem­
plars coming to fore and causing a “crisis”,
and so entailing a major revolution in the
field. Thus, for example, at one point phlo-
giston was thought to explain combustion,
but this paradigm was replaced by one
that emphasized the importance of oxy­
gen, providing an entirely new perspec­
tive. Notably, from a “critical” perspective,
scientific paradigms are incommensura­
ble; those who adopt different paradigms
are really talking past one another, and the
shift from one paradigm to another hap­
pens not because of scientific advance­
ment, but rather due to a sociopolitical
shift in the field228,229.
From this perspective, psychiatry has
been characterized by a history of contin­
ual paradigm shifts, with the field lurch­
ing over time from one set of models to
another, with no substantive scientific­ ad­
vances in our knowledge, but rather mere­ly
a responsiveness to the prevailing sociopo­
litical winds of the day229. Thus, as noted
earlier, psychiatry has seen movements
from psychodynamic approaches to neuro­
scientific ones, and from institutional care
to community-based care. While a good
deal of the critique of psychiatry has come
from external fields, there is a significant
contribution from within the discipline,
with proponents of new paradigms at times
being very critical of current practices.
World Psychiatry 21:3 - October 2022
The idea that psychiatry is in crisis seems
to be prevalent and persistent in both
the professional literature and in social
media230-234.
We would argue strongly against this
view of psychiatry. This is not to disagree
that there have been important shifts in the
field over its history: there certainly have
been. Nor is it to disagree with the valid
points that sociopolitical and sociocultural
factors are key to such issues as determin­
ing budgets for mental health services, and
in influencing the experience and expres­
sion of mental disorders235. Nor is to deny
or downplay the many crucial challenges
that continue to face psychiatry as a pro­
fession, and psychiatrists as practition­
ers236,237. And perhaps most importantly, it
is not to ignore or to minimize the enormi­
ty of the treatment and the research-prac­
tice gaps discussed in detail earlier in this
paper. Clearly, considerably more needs
to be done to improve mental health care
services, and to effectively address the bur­
den of disease due to mental disorder.
However, we wish to emphasize that
there has been a gradual accretion of
knowledge about mental disorders, and
that our understanding of their causes
and our ability to manage them has sig­
nificantly increased over time. We also
wish to argue that the different proposals
for the field discussed in this paper are not
necessarily incommensurable paradigms,
but rather are important perspectives
that can productively be drawn on and
integrated into contemporary practice238.
The integration of clinical neuroscience
and global mental health, for example,
may facilitate advances in precision pub­
lic mental health239. Space precludes a
detailed consideration of a range of other
innovative perspectives that may also con­
tribute to the incremental and integrative
advance of psychiatric practice, including
collaborative care240, preventive psychia­
try241, evolutionary psychiatry242, positive
psychiatry243, intergenerational psychia­
try244, and welfarist psychiatry245.
Perhaps most importantly, we would
wish to problematize the notion that psy­
chiatry is in perennial and perpetual cri­
sis. Tools provided by “critical” authors,
who emphasize the sociopolitical aspects
of science and medicine, may be in fact be
World Psychiatry 21:3 - October 2022
useful in investigating why psychiatry is so
often viewed in this way, and why a view
of psychiatry as steadily accreting knowl­
edge and improving clinical practices is
less often put forward than seems reason­
able, even from within the field. Are there
specific interests that stand to gain from
negative views of the psychiatric profes­
sion? What are the benefits to particular
authors of being overly critical of existing
practices and of promising entirely novel
or disruptive solutions? What can be done
to encourage those without and within the
field to emphasize that scientific progress
is often iterative and incremental, with
gradual consolidation of knowledge, with
inclusion and integration of a range of dif­
ferent models and approaches?
We have noted in this paper a number
of red flags, which seem indicative of overly
optimistic promises of a paradigm shift in
psychiatry practice and research, and that
may inadvertently even support an anti­
psychiatry position that discourages pa­
tients from seeking sorely needed profes­
sional care, or policy-makers from funding
desperately needed mental health care ser­
vices. A few of these red flags deserve par­
ticular emphasis here.
First, given the complexity of mental dis­
orders, and the need to avoid both a brain­
less and a mindless psychiatry246, various
forms of reductionism serve as red flags,
whether these involve neuro-reductionism
(e.g., mental disorders are merely brain dis­
orders) or culturalism (e.g., mental disor­
ders merely reflect social inequalities). As a
field, we should promote the breadth and
depth of psychiatric concepts and findings,
emphasizing that psychiatry builds bridges
across biological, psychological and social
domains, and that – despite the complex­
ity of mental disorders – this has allowed
important insights into their phenomenol­
ogy and etiology, and has facilitated the
development of a broad range of different
evidence-based treatment modalities and
types of intervention. The complexity of
mental disorders may, however, mean that
there are few “silver bullets” in psychiatry:
any individual mental health intervention
may have only modest effect sizes, and re­
duction of disease burden due to mental
disorders is a massive goal, likely requiring
a broad range of interventions247.
Second, economic over-optimism may
be a red flag: bringing new drugs to market
requires significant financial investment,
deinstitutionalization is not an inexpensive
option, and it is a challenge to demonstrate
that large-scale implementation programs
such as IAPT save money. While a range of
different metaphors may be useful in de­
scribing psychiatric work, and in encour­
aging policy-makers to fund mental health
services, we need perhaps to be particu­
larly careful of seeing patients as merely
consumers, and psychiatry as simply pro­
viding a return on investment. Similarly,
while a collaborative relationship between
professional clinicians and patient part­
ners may be useful in encouraging shared
decision-making, this metaphor of psychi­
atric work and mental health services may
miss some aspects of the clinical encoun­
ter. The metaphor of clinicians providing
care is a crucial one, and we need to call for
more such care, even if at times it is some­
what expensive115.
Third, calls for a radical transformation
of psychiatry’s research agenda are a red
flag. Hubris may result in downplaying
what has already been achieved over dec­
ades, or in overly focusing on one or other
favoured perspective. A more humble po­
sition that emphasizes how difficult is to
know what approaches and models will
lead to the largest advances, that encour­
ages a broad range of promising work, that
insists on principles of reproducible sci­
ence including the common metrics agen­
da, and that acknowledges the key role of
serendipity, is appropriate64,248,249. Analo­
gously, calls for a radical transformation or
narrowing of the training curriculum also
constitute a red flag: psychiatry trainees
need exposure to a broad range of concepts
and methods, including neuroscience, sta­
tistics, evidence-based psychotherapy, dig­
ital psychiatry, and public mental health.
The field needs well-rounded graduates
who are able to access and employ the full
range of concepts and findings from our
rich discipline.
How can we facilitate an ongoing focus
on incremental advances in clinical prac­
tice, with integration of a range of different
perspectives and findings? It may be use­
ful to approach the issues discussed in this
paper with a particular knowledge of how
409
science works, and with a particular atti­
tude towards progress.
From the perspective of knowledge, it
seems useful to emphasize that concepts
of scientific crisis and paradigm shifts of­
ten serve as rhetorical devices, that in sci­
ences ranging from physics to psychiatry
multiple approaches and models are
potentially useful, and that in psychiatry
there is a particular need for pluralistic
and pragmatic approaches that integrate a
range of different concepts, methods and
findings229,250. From the perspective of at­
titude, we would emphasize the value of
staying hopeful, avoiding hype, and com­
mitting to the important work of closing
the treatment gap as well as the research-
practice gap.
Thus, in terms used earlier in this paper,
the solution to challenges in psychiatric
diagnosis and treatment is unlikely to lie
in entirely novel paradigms, but rather in
the humble, laborious, iterative work of
systematic clinical observation, painstak­
ing research, and creative thinking. In the
case of psychiatric assessment, for exam­
ple, we have elsewhere argued for the need
for more work on post-diagnostic assess­
ments and measures that are consistent
with measurement-based care and that
promote personalized psychiatry251-253.
In the case of psychiatric treatment, ad­
dressing the treatment and the research-
practice gaps will require more attention
to expanding innovative delivery models
that will reach more people in need254, sys­
tematic adoption and roll-out of integrated
evidence-based interventions255, and an
iterative discovery-confirmation process
to assess and improve efficacy256.
In conclusion, this review of a range of
proposed approaches to and models of di­
agnosis and treatment of mental disorders
suggests caution in concluding that we are
facing a crisis in psychiatry which necessi­
tates a disruptive transitioning from tradi­
tional to new practices. We argue instead
that an approach which emphasizes para­
digm shifts should be replaced by one that
focuses on the importance and value of
incremental and integrative advances. In
particular, we caution against an advocacy
for paradigm shifts that inadvertently rep­
resents a disguised manifestation of anti­
psychiatry, and we instead suggest the need
410
for a position that emphasizes both the
accomplishments and limitations of psy­
chiatric diagnosis and treatment, and that
is cautiously optimistic about their future.
REFERENCES
1. Patel V, Saxena S, Lund C et al. The Lancet Com­
mission on global mental health and sustain­
able development. Lancet 2018;392:1553-98.
2. Collins PY. What is global mental health? World
Psychiatry 2020;19:265-6.
3. van Ginneken N, Chin WY, Lim YC et al. Prima­
ry-level worker interventions for the care of peo­
ple living with mental disorders and distress in
low- and middle-income countries. Cochrane
Database Syst Rev 2021;8:CD009149.
4. Mills C. Decolonizing global mental health: the
psychiatrization of the majority world. London:
Routledge, Taylor & Francis, 2014.
5. Wilson M. DSM-III and the transformation of
American psychiatry: a history. Am J Psychiatry
1993;150:399-410.
6. Kendler KS. A history of the DSM-5 scientific
review committee. Psychol Med 2013;43:1793-
800.
7. Reed GM, First MB, Kogan CS et al. Innova­
tions and changes in the ICD-11 classification of
mental, behavioural and neurodevelopmental
disorders. World Psychiatry 2019;18:3-19.
8. Cuthbert BN, Insel TR. Toward the future of psy­
chiatric diagnosis: the seven pillars of RDoC.
BMC Med 2013;11:126.
9. Deyo RA, Patrick DL. Hope or hype: the obses­
sion with medical advances and the high cost of
false promises. J Clin Invest 2005;115:2960.
10. Weissman SH. The evolution of psychiatric sub­
specialties. Psychiatr Q 1991;62:145-52.
11. First MB. Clinical utility in the revision of the Di­
agnostic and Statistical Manual of Mental Disor­
ders (DSM). Prof Psychol Res Pr 2010;41:465-73.
12. First MB, Gaebel W, Maj M et al. An organiza­
tion- and category-level comparison of diagnos­
tic requirements for mental disorders in ICD-11
and DSM-5. World Psychiatry 2021;20:34-51.
13. Moynihan R. Selling sickness: how the world’s
biggest pharmaceutical companies are turning
us all into patients. New York: National Books,
2005.
14. Clark LA, Cuthbert B, Lewis-Fernández R et al.
Three approaches to understanding and classi­
fying mental disorder: ICD-11, DSM-5, and the
National Institute of Mental Health’s Research
Domain Criteria (RDoC). Psychol Sci Public In­
terest 2017;18:72-145.
15. Engel G. The need for a new medical model: a
challenge for biomedicine. Science 1977;196:
129-36.
16. Álvarez AS, Pagani M, Meucci P. The clinical ap­
plication of the biopsychosocial model in men­
tal health: a research critique. Am J Phys Med
Rehabil 2012;91:S173-80.
17. Ghaemi SN. The rise and fall of the biopsycho­
social model: reconciling art and science in psy­
chiatry. Baltimore: Johns Hopkins University,
2010.
18. Bolton D, Gillett G. The biopsychosocial model of
health and disease: new philosophical and scien­
tific developments. Cham: Palgrave Pivot, 2019.
19. Kendler KS. The dappled nature of causes of
psychiatric illness: replacing the organic–func­
tional/hardware-software dichotomy with em­
pirically based pluralism. Mol Psychiatry 2012;
17:377-88.
20. Olfson M, Marcus SC. National trends in outpa­
tient psychotherapy. Am J Psychiatry 2010;167:
1456-63.
21. Hadjipavlou G, Hernandez CAS, Ogrodniczuk
JS. Psychotherapy in contemporary psychiatric
practice. Can J Psychiatry 2015;60:294-300.
22. World Health Organization. Mental health atlas
2020. Geneva: World Health Organization, 2021.
23. Munk-Jørgensen P, Blanner Kristiansen C, Uwa­
wke R et al. The gap between available knowl­
edge and its use in clinical psychiatry. Acta Psy­
chiatr Scand 2015;132:441-50.
24. Andrade LH, Alonso J, Mneimneh Z et al. Bar­
riers to mental health treatment: results from
the WHO World Mental Health surveys. Psychol
Med 2014;44:1303-17.
25. Zimmerman M. A review of 20 years of research
on overdiagnosis and underdiagnosis in the
Rhode Island Methods to Improve Diagnostic
Assessment and Services (MIDAS) Project. Can
J Psychiatry 2016;61:71-9.
26. Vigo D, Haro JM, Hwang I et al. Toward measur­
ing effective treatment coverage: critical bottle­
necks in quality- and user-adjusted coverage for
major depressive disorder. Psychol Med 2020;
doi: 10.1017/S0033291720003797.
27. Möller HJ, Maier W. Evidence-based medicine
in psychopharmacotherapy: possibilities, prob­
lems and limitations. Eur Arch Psychiatry Clin
Neurosci 2010;260:25-39.
28. Girlanda F, Fiedler I, Becker T et al. The evi­
dence-practice gap in specialist mental health­
care: systematic review and meta-analysis of
­guideline implementation studies. Br J Psychia­
try 2017;210:24-30.
29. Fulford KWM. Values-based practice: a new
partner to evidence-based practice and a first
for psychiatry. Mens Sana Monogr 2008;6:10-21.
30. Pincus HA, Zarin DA, Tanielian TL et al. Psy­
chiatric patients and treatments in 1997: find­
ings from the American Psychiatric Practice
Research Network. Arch Gen Psychiatry 1999;
56:441-9.
31. Leucht S, Hierl S, Kissling W et al. Putting the
efficacy of psychiatric and general medicine
medication into perspective: review of meta-
analyses. Br J Psychiatry 2012;200:97-106.
32. Harris MG, Kazdin AE, Munthali RJ et al. Per­
ceived helpfulness of service sectors used for
mental and substance use disorders: findings
from the WHO World Mental Health Surveys.
Int J Ment Health Syst 2022;16:6.
33. Chapman A, Williams C, Hannah J et al. Reim­
agining the mental health paradigm for our col­
lective well-being. Health Hum Rights 2020;
22:1-6.
34. Penzenstadler L, Khazaal Y, Fleury MJ. Editorial:
Community-based outreach treatment for ad­
dictions and concomitant disorders: time for a
change of paradigm. Front Psychiatry 2020;11:2.
35. Fu CHY, Costafreda SG. Neuroimaging-based
biomarkers in psychiatry: clinical opportunities
of a paradigm shift. Can J Psychiatry 2013;58:
499-508.
36. Leichsenring F, Steinert C, Ioannidis JPA. Toward
a paradigm shift in treatment and research of
mental disorders. Psychol Med 2019;49:2111-7.
37. Č      ešková E, Šilhán P. From personalized medi­
cine to precision psychiatry? Neuropsychiatr
Dis Treat 2021;17:3663-8.
World Psychiatry 21:3 - October 2022
38. Salazar de Pablo G, Studerus E, Vaquerizo-
Serrano J et al. Implementing precision psy­
chiatry: a systematic review of individualized
prediction models for clinical practice. Schizophr
Bull 2021;47:284-97.
39. Perna G, Grassi M, Caldirola D et al. The revolution
of personalized psychiatry: will technology make
it happen sooner? Psychol Med 2018;48:705-13.
40. Hyman SE. Can neuroscience be integrated into
the DSM-V? Nat Rev Neurosci 2007;8:725-32.
41. The Brainstorm Consortium, Anttila V, Bulik-
Sullivan B et al. Analysis of shared heritability
in common disorders of the brain. Science 2018;
360:eaap8757.
42. Hyman SE. Psychiatric disorders: grounded in
human biology but not natural kinds. Perspect
Biol Med 2021;64:6-28.
43. Kapur S, Phillips AG, Insel TR. Why has it taken
so long for biological psychiatry to develop clini­
cal tests and what to do about it? Mol Psychiatry
2012;17:1174-9.
44. Insel TR, Quirion R. Psychiatry as a clinical neu­
roscience discipline. JAMA 2005;294:2221-4.
45. Cuthbert BN. The RDoC framework: facilitating
transition from ICD/DSM to dimensional ap­
proaches that integrate neuroscience and psy­
chopathology. World Psychiatry 2014;13:28-35.
46. Fox AS, Kalin NH. A translational neuroscience
approach to understanding the development of
social anxiety disorder and its pathophysiology.
Am J Psychiatry 2014;171:1162-73.
47. Dougherty DD, Brennan BP, Stewart SE et al.
Neuroscientifically informed formulation and
treatment planning for patients with obsessive-
compulsive disorder: a review. JAMA Psychiatry
2018;75:1081-7.
48. Ressler KJ. Translating across circuits and genet­
ics toward progress in fear- and anxiety-related
disorders. Am J Psychiatry 2020;177:214-22.
49. Mataix-Cols D, Fernández de la Cruz L, Mon­
zani B et al. D-Cycloserine augmentation of
exposure-based cognitive behavior therapy for
anxiety, obsessive-compulsive, and posttrau­
matic stress disorders: a systematic review and
meta-analysis of individual participant data.
JAMA Psychiatry 2017;74:501-10.
50. Pollak SD. Developmental psychopathology:
recent advances and future challenges. World
Psychiatry 2015;14:262-9.
51. Teicher MH, Gordon JB, Nemeroff CB. Recog­
nizing the importance of childhood maltreat­
ment as a critical factor in psychiatric diagnoses,
treatment, research, prevention, and education.
Mol Psychiatry 2022;27:1331-8.
52. Van Praag HM, Asnis GM, Kahn RS et al. No­
sological tunnel vision in biological psychiatry.
A plea for a functional psychopathology. Ann
NY Acad Sci 1990;600:501-10.
53. Stein DJ. An integrative approach to psychiatric
diagnosis and research. World Psychiatry 2014;
13:51-3.
54. Murray GK, Lin T, Austin J et al. Could polygenic
risk scores be useful in psychiatry?: A review.
JAMA Psychiatry 2021;78:210-9.
55. Phillips EJ, Sukasem C, Whirl-Carrillo M et al.
Clinical Pharmacogenetics Implementation
Consortium guideline for HLA genotype and
use of carbamazepine and oxcarbazepine: 2017
update. Clin Pharmacol Ther 2018;103:574-81.
56. Bousman CA, Bengesser SA, Aitchison KJ et al.
Review and consensus on pharmacogenomic
testing in psychiatry. Pharmacopsychiatry 2021;
54:5-17.
World Psychiatry 21:3 - October 2022
57. Thompson PM, Jahanshad N, Ching CRK et al.
ENIGMA and global neuroscience: a decade of
large-scale studies of the brain in health and
disease across more than 40 countries. Transl
Psychiatry 2020;10:100.
58. Sullivan PF, Agrawal A, Bulik CM al et. Psychi­
atric genomics: an update and an agenda. Am J
Psychiatry 2018;175:15-27.
59. Choi KW, Stein MB, Nishimi KM et al. An ex­
posure-wide and Mendelian randomization
approach to identifying modifiable factors for
the prevention of depression. Am J Psychiatry
2020;177:944-54.
60. Weinberger DR, Radulescu E. Finding the elu­
sive psychiatric “lesion” with 21st-century neu­
roanatomy: a note of caution. Am J Psychiatry
2016;173:27-33.
61. Gordon JA. From neurobiology to novel medi­
cations: a principled approach to translation.
Am J Psychiatry 2019;176:425-7.
62. Arbuckle MR, Travis MJ, Eisen J et al. Transform­
ing psychiatry from the classroom to the clin­
ic: lessons from the National Neuroscience Cur­
riculum Initiative. Acad Psychiatry 2020;44:29-
36.
63. Carvalho AF, Solmi M, Sanches M et al. Evidence-
based umbrella review of 162 peripheral bio­
markers for major mental disorders. Transl Psy­
chiatry 2020;10:152.
64. Munafò MR, Nosek BA, Bishop DVM al et. A
manifesto for reproducible science. Nat Hum
Behav 2017;1:0021.
65. Hucklenbroich P. “Disease entity” as the key the­
oretical concept of medicine. J Med Philos 2014;
39:609-33.
66. Shorter E. The history of nosology and the rise of
the Diagnostic and Statistical Manual of Mental
Disorders. Dialogues Clin Neurosci 2015;17:59-
67.
67. Kendler KS. Philippe Pinel and the foundations
of modern psychiatric nosology. Psychol Med
2020;50:2667-72.
68. Ghaemi SN. DSM-5 and the miracle that never
happens. Acta Psychiatr Scand 2014;129:410-2.
69. Krueger RF, Kotov R, Watson D et al. Progress in
achieving quantitative classification of psycho­
pathology. World Psychiatry 2018;17:282-93.
70. Kotov R, Jonas KG, Carpenter WT et al. Validity
and utility of Hierarchical Taxonomy of Psycho­
pathology (HiTOP): I. Psychosis superspectrum.
World Psychiatry 2020;19:151-72.
71. Krueger RF, Hobbs KA, Conway CC et al. Va­
lidity and utility of Hierarchical Taxonomy of
Psychopathology (HiTOP): II. Externalizing su­
perspectrum. World Psychiatry 2021;20:171-93.
72. Watson D, Levin-Aspenson HF, Waszczuk MA et
al. Validity and utility of Hierarchical Taxonomy
of Psychopathology (HiTOP): III. Emotional
dysfunction superspectrum. World Psychiatry
2022;21:26-54.
73. Kotov R, Krueger RF, Watson D et al. The Hierar­
chical Taxonomy of Psychopathology (HiTOP):
a dimensional alternative to traditional nosolo­
gies. J Abnorm Psychol 2017;126:454-77.
74. McCrae RR, Costa PT. Validation of the five-fac­
tor model of personality across instruments and
observers. J Pers Soc Psychol 1987;52:81-90.
75. Achenbach TM. The classification of children’s
psychiatric symptoms: a factor-analytic study.
Psychol Monogr 1966;80:1-37.
76. Caspi A, Moffitt TE. All for one and one for all:
mental disorders in one dimension. Am J Psy­
chiatry 2018;175:831-44.
77. Pettersson E, Larsson H, D’Onofrio BM et al.
The general factor of psychopathology: a com­
parison with the general factor of intelligence
with respect to magnitude and predictive valid­
ity. World Psychiatry 2020;19:206-13.
78. Borsboom D. A network theory of mental disor­
ders. World Psychiatry 2017;16:5-13.
79. Ohlsson H, Kendler KS. Applying causal infer­
ence methods in psychiatric epidemiology: a
review. JAMA Psychiatry 2020;77:637-44.
80. Richmond RC, Davey Smith G. Mendelian ran­
domization: concepts and scope. Cold Spring
Harb Perspect Med 2022;12:a040501.
81. Dwyer DB, Falkai P, Koutsouleris N. Machine
learning approaches for clinical psychology and
psychiatry. Annu Rev Clin Psychol 2018;14:91-
118.
82. Rutledge RB, Chekroud AM, Huys QJ. Machine
learning and big data in psychiatry: toward clin­
ical applications. Curr Opin Neurobiol 2019;55:
152-9.
83. Koppe G, Meyer-Lindenberg A, Durstewitz D.
Deep learning for small and big data in psychia­
try. Neuropsychopharmacology 2021;46:176-90.
84. Checkroud AM, Bondar J, Delgadillo J et al. The
promise of machine learning in predicting treat­
ment outcomes in psychiatry. World Psychiatry
2021;20:154-93.
85. Bourla A, Ferreri F, Ogorzelec L et al. Psychia­
trists’ attitudes toward disruptive new technolo­
gies: mixed-methods study. JMIR Ment Health
2018;5:e10240.
86. Cramer AOJ, Waldorp LJ, van der Maas HLJ et
al. Comorbidity: a network perspective. Behav
Brain Sci 2010;33:137-50.
87. Kessler RC. The categorical versus dimensional
assessment controversy in the sociology of men­
tal illness. J Health Soc Behav 2002;43:171-88.
88. Potuzak M, Ravichandran C, Lewandowski KE
et al. Categorical vs dimensional classifications
of psychotic disorders. Compr Psychiatry 2012;53:
1118-29.
89. Fulford KWM, Handa A. Categorical and/or
continuous? Learning from vascular surgery.
World Psychiatry 2018;17:304-5.
90. Eaton WW, McCutcheon A, Dryman A et al.
Latent class analysis of anxiety and depression.
Sociol Methods Res 1989;18:104-25.
91. Kendler KS, First MB. Alternative futures for the
DSM revision process: iteration v. paradigm
shift. Br J Psychiatry 2010;197:263-5.
92. Kratochwill TR, Horner RH, Levin JR et al.
Single-case design standards: an update and
proposed upgrades. J School Psychol 2021;89:
91-105.
93. London AJ. Artificial intelligence and black-box
medical decisions: accuracy versus explainabil­
ity. Hastings Cent Rep 2019;49:15-21.
94. Quinn TP, Jacobs S, Senadeera M et al. The three
ghosts of medical AI: can the black-box present
deliver? Artif Intell Med 2022;124:102158.
95. Torrey EF. Out of the shadows: confronting Amer­
ica’s mental illness crisis. Chichester: Wiley, 1997.
96. Lamb HR, Bachrach LL. Some perspectives
on deinstitutionalization. Psychiatr Serv 2001;52:
1039-45.
97. Knapp M, Chisholm D, Astin J et al. The cost
consequences of changing the hospital-com­
munity balance: the mental health residential
care study. Psychol Med 1997;27:681-92.
98. Slade M. Implementing shared decision making
in routine mental health care. World Psychiatry
2017;16:146-53.
411
99. Lora A. An overview of the mental health system
in Italy. Ann Ist Super Sanita 2009;45:5-16.
100. Mladenov T, Petri G. Critique of deinstitution­
alisation in postsocialist Central and Eastern
Europe. Disabil Soc 2020;35:1203-26.
101. Lund C. Mental health and human rights in
South Africa: the hidden humanitarian crisis. S
Afr J Hum Rights 2016;32:403-5.
102. Vigod SN, Kurdyak PA, Dennis CL et al. Transi­
tional interventions to reduce early psychiatric
readmissions in adults: systematic review. Br J
Psychiatry 2013;202:187-94.
103. World Health Organization. Mental health pol­
icy, plans and programmes. Geneva: World Health
Organization, 2005.
104. Thornicroft G, Tansella M. The balanced care
model for global mental health. Psychol Med
2013;43:849-63.
105. Unützer J, Carlo AD, Collins PY. Leveraging
collaborative care to improve access to mental
health care on a global scale. World Psychiatry
2020;19:36-7.
106. World Health Organization. mhGAP intervention
guide for mental, neurological and substance use
disorders in non-specialized health settings: men­
tal health Gap Action Programme (mhGAP). ver­
sion 2.0. Geneva: World Health Organization, 2016.
107. Coulter A, Entwistle VA, Eccles A et al. Person­
alised care planning for adults with chronic or
long-term health conditions. Cochrane Data­
base Syst Rev 2015;3:CD010523.
108. Fulford KWM, Handa A. New resources for
understanding patients’ values in the context
of shared clinical decision-making. World Psy­
chiatry 2021;20:446-7.
109. Slade M, Amering M, Farkas M et al. Uses and
abuses of recovery: implementing recovery-ori­
ented practices in mental health systems. World
Psychiatry 2014;13:12-20.
110. Waddell A, Lennox A, Spassova G et al. Barriers
and facilitators to shared decision-making in
hospitals from policy to practice: a systematic
review. Implement Sci 2021;16:74.
111. Roberts T, Miguel Esponda G, Torre C et al.
Reconceptualising the treatment gap for com­
mon mental disorders: a fork in the road for
global mental health? Br J Psychiatry 2022;
10.1192/bjp.2021.221
112. Arango C, Dragioti E, Solmi M et al. Risk and
protective factors for mental disorders beyond
genetics: an evidence-based atlas. World Psy­
chiatry 2021;20:417-36.
113. Gureje O, Appiah-Poku J, Bello T et al. Effect of
collaborative care between traditional and faith
healers and primary health-care workers on
psychosis outcomes in Nigeria and Ghana (CO­
SIMPO): a cluster randomised controlled trial.
Lancet 2020;396:612-22.
114. Jordans MJ, Kohrt BA, Luitel NP et al. Proactive
community case-finding to facilitate treatment
seeking for mental disorders, Nepal. Bull World
Health Organ 2017;95:531-6.
115. Stein DJ. Psychiatric practice: caring for patients,
collaborating with partners, or marketing to
consumers? World Psychiatry 2017;16:156-7.
116. Talbott JA. Twentieth-century developments in
American psychiatry. Psychiatr Q 1982;54:207-
19.
117. Hofmann SG, Asnaani A, Vonk IJJ et al. The effi­
cacy of cognitive behavioral therapy: a review of
meta-analyses. Cogn Ther Res 2012;36:427-40.
118. Driessen E, Dekker JJM, Peen J et al. The efficacy
of adding short-term psychodynamic psycho­
412
therapy to antidepressants in the treatment of
depression: a systematic review and meta-anal­
ysis of individual participant data. Clin Psychol
Rev 2020;80:101886.
119. Cuijpers P, Driessen E, Hollon SD et al. The ef­
ficacy of non-directive supportive therapy for
adult depression: a meta-analysis. Clin Psychol
Rev 2012;32:280-91.
120. Cuijpers P, Quero S, Noma H et al. Psychothera­
pies for depression: a network meta-analysis
covering efficacy, acceptability and long-term
outcomes of all main treatment types. World
Psychiatry 2021;20:283-93.
121. Cook SC, Schwartz AC, Kaslow NJ. Evidence-
based psychotherapy: advantages and chal­
lenges. Neurotherapeutics 2017;14:537-45.
122. Wolpe J. The formation of negative habits: a neu­
rophysiological view. Psychol Rev 1952;59:290-
9.
123. Beck AT. The evolution of the cognitive model
of depression and its neurobiological correlates.
Am J Psychiatry 2008;165:969-77.
124. Hayes SC, Hofmann SG. “Third-wave” cognitive
and behavioral therapies and the emergence
of a process-based approach to intervention in
psychiatry. World Psychiatry 2021;20:363-75.
125. Amouroux R. Beyond indifference and aver­
sion: the critical reception and belated accept­
ance of behavior therapy in France. Hist Psychol
2017;20:313-29.
126. Olfson M, Marcus SC. National patterns in an­
tidepressant medication treatment. Arch Gen
Psychiatry 2009;66:848-56.
127. McHugh RK, Whitton SW, Peckham AD et al.
Patient preference for psychological vs phar­
macologic treatment of psychiatric disorders: a
meta-analytic review. J Clin Psychiatry 2013;74:
595-602.
128. Grimshaw J, Thomas R, MacLennan G et al. Ef­
fectiveness and efficiency of guideline dissemi­
nation and implementation strategies. Health
Technol Assess 2004;8:iii-iv.
129. Barth JH, Misra S, Aakre KM et al. Why are clini­
cal practice guidelines not followed? Clin Chem
Lab Med 2016;54:1133-9.
130. Gagliardi AR, Brouwers MC, Palda VA et al. How
can we improve guideline use? A conceptual
framework of implementability. Implement Sci
2011;6:26.
131. Layard R, Clark D, Knapp M et al. Cost-benefit
analysis of psychological therapy. Natl Inst Econ
Rev 2007;202:90-8.
132. Chisholm D, Sweeny K, Sheehan P et al. Scaling-
up treatment of depression and anxiety: a global
return on investment analysis. Lancet Psychia­
try 2016;3:415-24.
133. Clark DM. Realizing the mass public benefit of
evidence-based psychological therapies: the
IAPT program. Annu Rev Clin Psychol 2018;14:
159-83.
134. Marks DF. IAPT under the microscope. J Health
Psychol 2018;23:1131-5.
135. Scott MJ. Improving Access to Psychological
Therapies (IAPT) – the need for radical reform.
J Health Psychol 2018;23:1136-47.
136. Gyani A, Shafran R, Layard R et al. Enhancing
recovery rates: lessons from year one of IAPT.
Behav Res Ther 2013;51:597-606.
137. Clark DM, Canvin L, Green J et al. Transparency
about the outcomes of mental health services
(IAPT approach): an analysis of public data.
Lancet 2018;391:679-86.
138. Wakefield S, Kellett S, Simmonds-Buckley M et
al. Improving Access to Psychological Therapies
(IAPT) in the United Kingdom: a systematic re­
view and meta-analysis of 10-years of practice-
based evidence. Br J Clin Psychol 2021;60:1-37.
139. Cromarty P, Drummond A, Francis T et al.
NewAccess for depression and anxiety: adapting
the UK Improving Access to Psychological Thera­
pies program across Australia. Australas Psychia­
try 2016;24:489-92.
140. Naeem F, Pikard J, Rao S et al. Is it possible to
provide low-intensity cognitive behavioral treat­
ment (CBT Lite) in Canada without additional
costs to the health system? First-year evaluation
of a pilot CBT Lite program. Int J Ment Health
2017;46:253-68.
141. Knapstad M, Nordgreen T, Smith ORF. Prompt
mental health care, the Norwegian version of
IAPT: clinical outcomes and predictors of change
in a multicenter cohort study. BMC Psychiatry
2018;18:260.
142. Kobori O, Nakazato M, Yoshinaga N et al. Trans­
porting cognitive behavioral therapy (CBT) and
the Improving Access to Psychological Thera­
pies (IAPT) project to Japan: preliminary obser­
vations and service evaluation in Chiba. J Ment
Health Train Educ Pract 2014;9:155-66.
143. Twomey C, O’Reilly G. Effectiveness of a freely
available computerised cognitive behavioural
therapy programme (MoodGYM) for depression:
meta-analysis. Aust N Z J Psychiatry 2017;51:260-9.
144. Rahman A, Hamdani SU, Awan NR et al. Effect
of a multicomponent behavioral intervention
in adults impaired by psychological distress in a
conflict-affected area of Pakistan: a randomized
clinical trial. JAMA 2016;316:2609.
145. Rahman A, Khan MN, Hamdani SU et al. Ef­
fectiveness of a brief group psychological in­
tervention for women in a post-conflict setting
in Pakistan: a single-blind, cluster, randomised
controlled trial. Lancet 2019;393:1733-44.
146. Timimi S. The diagnosis is correct, but National
Institute of Health and Care Excellence guide­
lines are part of the problem not the solution. J
Health Psychol 2018;23:1148-52.
147. Martin C, Iqbal Z, Airey ND et al L. Improving
Access to Psychological Therapies (IAPT) has
potential but is not sufficient: how can it better
meet the range of primary care mental health
needs? Br J Clin Psychol 2022;61:157-74.
148. Andrews G, Issakidis C, Sanderson K et al. Utilis­
ing survey data to inform public policy: compar­
ison of the cost-effectiveness of treatment of ten
mental disorders. Br J Psychiatry 2004;184:526-
33.
149. Ormel J, Hollon SD, Kessler RC et al. More treat­
ment but no less depression: the treatment-
pre­valence paradox. Clin Psychol Rev 2022;91:
102111.
150. Ferrari AJ, Charlson FJ, Norman RE et al. Burden
of depressive disorders by country, sex, age, and
year: findings from the Global Burden of Dis­
ease study 2010. PLoS Med 2013;10:e1001547.
151. Leichsenring F, Steinert C, Rabung S et al. The
efficacy of psychotherapies and pharmacothera­
pies for mental disorders in adults: an umbrella
review and meta-analytic evaluation of recent
meta-analyses. World Psychiatry 2022;21:133-45.
152. Cuijpers P, Karyotaki E, Reijnders M et al. Was
Eysenck right after all? A reassessment of the
effects of psychotherapy for adult depression.
Epidemiol Psychiatr Sci 2019;28:21-30.
153. Torous J, Bucci S, Bell IH et al. The growing field
of digital psychiatry: current evidence and the
World Psychiatry 21:3 - October 2022
 future of apps, social media, chatbots, and vir­
tual reality. World Psychiatry 2021;20:318-35.
154. Kinoshita S, Cortright K, Crawford A et al. Chang­
es in telepsychiatry regulations during the COV­
ID-19 pandemic: 17 countries and re­gions’ ap­
proaches to an evolving healthcare landscape.
Psychol Med 2020; 10.1017/S0033291720004584.
155. Insel TR. Digital phenotyping: a global tool for
psychiatry. World Psychiatry 2018;17:276-7.
156. Bardram JE, Matic A. A decade of ubiquitous
computing research in mental health. IEEE Per­
vasive Comput 2020;19:62-72.
157. Hirschtritt ME, Insel TR. Digital technologies in
psychiatry: present and future. Focus (Am Psy­
chiatr Publ) 2018;16:251-8.
158. Mishkind MC, Norr AM, Katz AC et al. Review of
virtual reality treatment in psychiatry: evidence
versus current diffusion and use. Curr Psychia­
try Rep 2017;19:80.
159. Abd-Alrazaq AA, Rababeh A, Alajlani M et al.
Effectiveness and safety of using chatbots to im­
prove mental health: systematic review and me­
ta-analysis. J Med Internet Res 2020;22:e16021.
160. Onie S, Li X, Liang M et al. The use of closed-cir­
cuit television and video in suicide prevention:
narrative review and future directions. JMIR
Ment Health 2021;8:e27663.
161. Rohani DA, Faurholt-Jepsen M, Kessing LV et
al. Correlations between objective behavioral
features collected from mobile and wearable
devices and depressive mood symptoms in pa­
tients with affective disorders: systematic re­
view. JMIR mHealth uHealth 2018;6:e165.
162. Low DM, Bentley KH, Ghosh SS. Automated as­
sessment of psychiatric disorders using speech:
a systematic review. Laryngoscope Investig Oto­
laryngol 2020;5:96-116.
163. Sano A, Taylor S, McHill AW et al. Identifying
objective physiological markers and modifiable
behaviors for self-reported stress and mental
health status using wearable sensors and mo­
bile phones: observational study. J Med Internet
Res 2018;20:e210.
164. Ghosh S, Sahu S, Ganguly N et al. EmoKey: an
emotion-aware smartphone keyboard for men­
tal health monitoring. Presented at the 11th
International Conference on Communication
Systems & Networks, Bangalore, January 2019.
165. O’Dea B, Larsen ME, Batterham PJ et al. A lin­
guistic analysis of suicide-related twitter posts.
Crisis 2017;38:319-29.
166. Silver L. Smartphone ownership is growing rap­
idly around the world, but not always equally.
Pew Research Center, February 5, 2019.
167. Huckvale K, Nicholas J, Torous J et al. Smart­
phone apps for the treatment of mental health
conditions: status and considerations. Curr
Opin Psychol 2020;36:65-70.
168. Lecomte T, Potvin S, Corbière M et al. Mobile
apps for mental health issues: meta-review of
meta-analyses. JMIR mHealth uHealth 2020;8:
e17458.
169. Torous J, Wisniewski H, Liu G et al. Mental
health mobile phone app usage, concerns, and
benefits among psychiatric outpatients: com­
parative survey study. JMIR Ment Health 2018;5:
e11715.
170. Firth J, Torous J, Nicholas J et al. The efficacy of
smartphone-based mental health interventions
for depressive symptoms: a meta-analysis of
randomized controlled trials. World Psychiatry
2017;16:287-98.
171. Firth J, Torous J, Nicholas J et al. Can smartphone
World Psychiatry 21:3 - October 2022
mental health interventions reduce symptoms
of anxiety? A meta-analysis of randomized con­
trolled trials. J Affect Disord 2017;218:15-22.
172. Torous J, Haim A. Dichotomies in the develop­
ment and implementation of digital mental
health tools. Psychiatr Serv 2018;69:1204-6.
173. Connolly SL, Hogan JB, Ecker AH et al. Telepsy­
chiatry and video-to-home (including security
issues). In: Stein D, Fineberg N, Chamberlain S
(eds). Mental health in a digital world. Amster­
dam: Elsevier, 2022:147-67.
174. Zulueta J, Ajilore OA. Beyond non-inferior: how
telepsychiatry technologies can lead to superior
care. Int Rev Psychiatry 2021;33:366-71.
175. Targum SD, Sauder C, Evans M et al. Ecological
momentary assessment as a measurement tool
in depression trials. J Psychiatr Res 2021;136:256-
64.
176. Weizenbaum E, Torous J, Fulford D. Cognition
in context: understanding the everyday predic­
tors of cognitive performance in a new era of
measurement. JMIR mHealth uHealth 2020;8:
e14328.
177. Torous J, Kiang MV, Lorme J et al. New tools for
new research in psychiatry: a scalable and cus­
tomizable platform to empower data driven
smartphone research. JMIR Ment Health 2016;3:
e16.
178. Gaggioli A, Pioggia G, Tartarisco G et al. A mo­
bile data collection platform for mental health
research. Pers Ubiquitous Comput 2013;17:241-
51.
179. Torous J, Hsin H. Empowering the digital thera­
peutic relationship: virtual clinics for digital
health interventions. NPJ Digit Med 2018;1:16.
180. Huckvale K, Venkatesh S, Christensen H. To­
ward clinical digital phenotyping: a timely op­
portunity to consider purpose, quality, and
safety. NPJ Digit Med 2019;2:88.
181. Majumder S, Deen MJ. Smartphone sensors for
health monitoring and diagnosis. Sensors 2019;
19:2164.
182. Keusch F, Wenz A, Conrad F. Do you have your
smartphone with you? Behavioral barriers for
measuring everyday activities with smartphone
sensors. Comput Hum Behav 2022;127:107054.
183. Bauer M, Glenn T, Geddes J et al. Smartphones
in mental health: a critical review of background
issues, current status and future concerns. Int J
Bipolar Disord 2020;8:2.
184. Nicholas J, Larsen ME, Proudfoot J et al. Mobile
apps for bipolar disorder: a systematic review of
features and content quality. J Med Internet Res
2015;17:e198.
185. Wilson H, Stoyanov SR, Gandabhai S et al. The
quality and accuracy of mobile apps to prevent
driving after drinking alcohol. JMIR mHealth
uHealth 2016;4:e98.
186. Mani M, Kavanagh DJ, Hides L et al. Review and
evaluation of mindfulness-based iPhone apps.
JMIR mHealth uHealth 2015;3:e82.
187. Torous J, Nicholas J, Larsen ME et al. Clinical re­
view of user engagement with mental health
smartphone apps: evidence, theory and im­
provements. Evid Based Ment Health 2018;21:
116-9.
188. Larsen ME, Huckvale K, Nicholas J et al. Using
science to sell apps: evaluation of mental health
app store quality claims. NPJ Digit Med 2019;
2:18
189. Powell A, Singh P, Torous J. The complexity of
mental health app privacy policies: a potential
barrier to privacy. JMIR mHealth uHealth 2018;
6:e158.
190. Watts G. COVID-19 and the digital divide in the
UK. Lancet Digit Health 2020;2:e395-6.
191. Carter H, Araya R, Anjur K et al. The emergence
of digital mental health in low-income and
middle-income countries: a review of recent ad­
vances and implications for the treatment and
prevention of mental disorders. J Psychiatr Res
2021;133:223-46.
192. Schueller SM, Neary M, O’Loughlin K et al.
Discovery of and interest in health apps among
those with mental health needs: survey and
focus group study. J Med Internet Res 2018;20:
e10141.
193. Hanson K, Gilson L, Goodman C et al. Is private
health care the answer to the health problems of
the world’s poor? PLoS Med 2008;5:e233.
194. Keefe PR. Empire of pain: the secret history of
the Sackler Dynasty. Toronto: Bond Street Books,
2021.
195. Martin A, Pugmire J, Wells V et al. Systematic lit­
erature review of the relationship between ado­
lescents’ screen time, sleep and mental health.
Edinburgh: Scottish Government, 2020.
196. Ashton JJ, Beattie RM. Screen time in children
and adolescents: is there evidence to guide par­
ents and policy? Lancet Child Adolesc Health
2019;3:292-4.
197. Sohn SY, Rees P, Wildridge B et al. Prevalence of
problematic smartphone usage and associated
mental health outcomes amongst children and
young people: a systematic review, meta-analy­
sis and GRADE of the evidence. BMC Psychiatry
2019;19:356.
198. Tang S, Werner-Seidler A, Torok M et al. The
relationship between screen time and men­
tal health in young people: a systematic re­
view of longitudinal studies. Clin Psychol Rev
2021;86:102021.
199. Wang X, Li Y, Fan H. The associations between
screen time-based sedentary behavior and de­
pression: a systematic review and meta-analy­
sis. BMC Publ Health 2019;19:1524.
200. Ebert DD, Van Daele T, Nordgreen T et al. In­
ternet- and mobile-based psychological inter­
ventions: applications, efficacy, and potential
for improving mental health. Eur Psychol 2018;
23:167-87.
201. Bader CS, Skurla M, Vahia IV. Technology in the
assessment, treatment, and management of de­
pression. Harv Rev Psychiatry 2020;28:60-6.
202. Bantjes J, Slabbert P. The digital therapeutic re­
lationship: retaining humanity in the digital age.
In: Stein D, Fineberg N, Chamberlain S (eds).
Mental health in a digital world. Amsterdam:
Elsevier, 2022:223-37.
203. Mohr DC, Weingardt KR, Reddy M et al. Three
problems with current digital mental health
research… and three things we can do about
them. Psychiatr Serv 2017;68:427-9.
204. Stein DJ, Naslund JA, Bantjes J. COVID-19 and
the global acceleration of digital psychiatry.
Lancet Psychiatry 2022;9:8-9.
205. Chen X. Understanding the development and
perception of global health for more effective
student education. Yale J Biol Med 2014;87:231-
40.
206. Brown TM, Cueto M, Fee E. The World Health
Organization and the transition from “interna­
tional” to “global” public health. Am J Public
Health 2006;96:62-72.
207. Salm M, Ali M, Minihane M et al. Defining glob­
al health: findings from a systematic review and
413
 thematic analysis of the literature. BMJ Glob
Health 2021;6:e005292.
208. Kolappa K, Henderson DC, Kishore SP. No
physical health without mental health: lessons
unlearned? Bull World Health Organ 2013;91:3-
3A.
209. Stein DJ, Benjet C, Gureje O et al. Integrating
mental health with other non-communicable
diseases. BMJ 2019;364:l295.
210. Becker AE, Kleinman A. Mental health and the
global agenda. N Engl J Med 2013;369:1380-1.
211. Sartorius N, Harding TW. The WHO collabora­
tive study on strategies for extending mental
health care, I: The genesis of the study. Am J Psy­
chiatry 1983;140:1470-3.
212. Gureje O, Hollins S, Botbol M et al. Report of the
WPA task force on brain drain. World Psychiatry
2009;8:115-8.
213. Sartorius N. Methodologic problems of com­
mon terminology, measurement, and classifi­
cation. 11. Modifications and new approaches
to taxonomy in long-term care: advantages and
limitations of the ICD. Med Care 1976;14(Suppl.
5):109-15.
214. Singla DR, Kohrt BA, Murray LK et al. Psycho­
logical treatments for the world: lessons from
low- and middle-income countries. Annu Rev
Clin Psychol 2017;13:149-81.
215. Kohrt BA, Jordans MJD, Rai S et al. Therapist
competence in global mental health: develop­
ment of the ENhancing Assessment of Common
Therapeutic factors (ENACT) rating scale. Behav
Res Ther 2015;69:11-21.
216. Kohrt BA, Schafer A, Willhoite A et al. Ensuring
Quality in Psychological Support (WHO EQUIP)
developing a competent global workforce. World
Psychiatry 2020;19:115-6.
217. Knapp M, Wong G. Economics and mental health:
the current scenario. World Psychiatry 2020;19:
3-14.
218. Votruba N, Grant J, Thornicroft G. The EVITA
framework for evidence-based mental health
policy agenda setting in low- and middle-income
countries. Health Policy Plan 2020;35:424-39.
219. Thornicroft G, Mehta N, Clement S et al. Evi­
dence for effective interventions to reduce men­
tal-health-related stigma and discrimination.
Lancet 2016;387:1123-32.
220. Pickard H. Responsibility without blame for ad­
diction. Neuroethics 2017;10:169-80.
221. Lebowitz MS, Appelbaum PS. Biomedical ex­
planations of psychopathology and their impli­
cations for attitudes and beliefs about mental
disorders. Annu Rev Clin Psychol 2019;15:555-
77.
222. Lund C, Brooke-Sumner C, Baingana F et al.
Social determinants of mental disorders and the
Sustainable Development Goals: a systematic
414
review of reviews. Lancet Psychiatry 2018;5:357-
69.
223. Shah N, Walker IF, Naik Y et al. National or pop­
ulation level interventions addressing the social
determinants of mental health – an umbrella
review. BMC Public Health 2021;21:2118.
224. Misra S, Stevenson A, Haroz EE et al. ‘Global
mental health’: systematic review of the term
and its implicit priorities. BJPsych Open 2019;5:
e47.
225. Osborn TL, Wasil AR, Weisz JR et al. Where is the
global in global mental health? A call for inclu­
sive multicultural collaboration. Gen Psychiatry
2020;33:e100351.
226. Richards RJ, Daston L (eds). Kuhn’s structure
of scientific revolutions at fifty: reflections on a
science classic. Chicago: University of Chicago
Press, 2016.
227. Kuhn TS. Structure of scientific revolutions. Chi­
cago: University of Chicago Press, 1962.
228. Morris E. The Ashtray (or the man who denied re­
ality). Chicago: University of Chicago Press, 2018.
229. Stein D. Problems of living: perspectives from
philosophy, psychiatry and cognitive-affective
science. Cambridge: Academic Press, 2021.
230. Goldberg D. Findings from “London’s Mental
Health”: a service in crisis. Acta Psychiatr Scand
2000;101:57-60.
231. Wise J. Mental health: patients and service in
crisis. BMJ 2017;356:j1141.
232. Melnyk BM. The child & adolescent mental
health crisis: closing the service gap. Imprint 2007
;54:58-63.
233. Kirwin P. Canary in a coal mine: geriatric psy­
chiatry in crisis. Am J Geriatr Psychiatry 2016;24:
690-2.
234. Jablensky A. Psychiatry in crisis? Back to funda­
mentals. World Psychiatry 2010;9:29-29.
235. Kleinman A. Rethinking psychiatry: from cultur­
al category to personal experience. New York:
Free Press, 1988.
236. Katschnig H. Are psychiatrists an endangered
species? Observations on internal and external
challenges to the profession. World Psychiatry
2010;9:21-8.
237. Bhugra D, Tasman A, Pathare S et al. The WPA-
Lancet Psychiatry Commission on the Future of
Psychiatry. Lancet Psychiatry 2017;4:775-818.
238. Stein DJ, He Y, Phillips A et al. Global mental
health and neuroscience: potential synergies.
Lancet Psychiatry 2015;2:178-85.
239. Desmond-Hellmann S. Progress lies in preci­
sion. Science 2016;353:731.
240. Overbeck G, Davidsen AS, Kousgaard MB. En­
ablers and barriers to implementing collabo­rative
care for anxiety and depression: a system­atic qual­
itative review. Implement Sci 2016;11:165.
241. Fusar-Poli P, Correll CU, Arango C et al. Preven­
tive psychiatry: a blueprint for improving the
mental health of young people. World Psychia­
try 2021;20:200-21.
242. Nesse RM, Stein DJ. How evolutionary psychi­
atry can advance psychopharmacology. Dia­
logues Clin Neurosci 2019;21:167-75.
243. Jeste D, Palmer B. Positive psychiatry: a clinical
handbook. Washington: American Psychiatric
Association Publishing, 2015.
244. Duarte CS, Monk C, Weissman MM et al. Inter­
generational psychiatry: a new look at a power­
ful perspective. World Psychiatry 2020;19:175-6.
245. McConnell D, Savulescu J. Welfarist psychiatry
goes global. In: Stein D, Singh I (eds). Global men­
tal health and neuroethics. London: Elsevier/
Academic Press, 2020:37-54.
246. Eisenberg L. The subjective in medicine. Per­
spect Biol Med 1983;27:48-61.
247. Stein DJ. Is there a “mosquito net” for anxiety
and mood disorders? Curr Psychiatry Rep 2009;
11:264-5.
248. Ban TA. The role of serendipity in drug discov­
ery. Dialogues Clin Neurosci 2006;8:335-44.
249. Krause KR, Chung S, Sousa Fialho MDL et al.
The challenge of ensuring affordability, sus­
tainability, consistency, and adaptability in the
common metrics agenda. Lancet Psychiatry
2021;8:1094-102.
250. Zachar P, Kendler KS. The philosophy of nosol­
ogy. Annu Rev Clin Psychol 2017;13:49-71.
251. Maj M, Stein DJ, Parker G et al. The clinical char­
acterization of the adult patient with depres­
sion aimed at personalization of management.
World Psychiatry 2020;19:269-93.
252. Maj M, van Os J, De Hert M et al. The clinical
characterization of the patient with primary
psychosis aimed at personalization of manage­
ment. World Psychiatry 2021;20:4-33.
253. Stein DJ, Craske MG, Rothbaum BO et al. The
clinical characterization of the adult patient
with an anxiety or related disorder aimed at per­
sonalization of management. World Psychiatry
2021;20:336-56.
254. Kazdin AE. Addressing the treatment gap: a key
challenge for extending evidence-based psycho­
social interventions. Behav Res Ther 2017;88:7-
18.
255. Graham BM, Callaghan BL, Richardson R. Bridg­
ing the gap: lessons we have learnt from the
merging of psychology and psychiatry for the op­
timisation of treatments for emotional disorders.
Behav Res Ther 2014;62:3-16.
256. Kessler RC, Luedtke A. Pragmatic precision
psychiatry – a new direction for optimizing
treatment selection. JAMA Psychiatry 2021;78:
1384-90.
DOI:10.1002/wps.20998
World Psychiatry 21:3 - October 2022